Kindly Fill Out The Patient's Form This Form Is Necessary For Your MMJ Evaluation
Please select the condition for which you seek medical marijuana. Chronic Pain PTSD Spinal Cord Injury With Spasticity Epilepsy Amyotrophic Lateral Sclerosis Cancer Inflammatory Bowel Decease Neuropathy/Radiculopathy Huntington's Disease HIV/AIDS Parkinson's Disease
For how long you are experiencing it? 3-6 Months 6-9 Months 1-2 Years 5-10 Years
If it's chronic pain, what is the cause of it? Traum/ Fall Motor Vehicle Accident Other
Are you taking any other medication?
Have you ever been diagnosed with schizophrenia?
Have you ever experienced hallucinations before?
Do you smoke cigarettes?
Do you drink alcohol?
The patient tried and had a failure of other alternatives, and appropriate time was spent on discussing the risks, including but not limited to addiction.
Avoid operating heavy machinery and driving under the influence of cannabis.
I will not grow cannabis in my household.
Keep away from children.
Upload a valid New York State ID
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securely in the HIPAA - compliant database.
Take a clear picture of your identification.
Valid state ID/License, Passport, US Viasa.
The other US government-issued ID, bills
are ok to upload too!
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