Get Patient Intake Questionnaire - Serenity Medical Marijuana

Filling out the Patient Intake Questionnaire is an essential step in the process of obtaining a recommendation for medical cannabis. This guide will provide clear instructions on how to complete the form accurately and efficiently in an online format.

Follow the steps to complete the Patient Intake Questionnaire.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering your personal information. Fill in your name, including your first, middle, and last name, followed by the date.
3. Next, provide your address details, including your street, city, state, and zip code, along with your telephone number, email, and a preferred text number if applicable.
4. Indicate whether we may contact you by email or text, then specify your age and occupation.
5. Describe your current medical complaint clearly in the designated section.
6. State whether you are currently under the care of a physician and provide the name and contact information for your primary care physician if applicable.
7. Note if you brought any medical records or documentation to support your application.
8. Answer questions regarding any previous evaluations for medical marijuana, including any denials and your educational status.
9. Fill out relevant sections regarding your mental and physical health history, including any medications, treatment programs, and hospitalizations.
10. Complete the family health history and personal symptom checklist as indicated.
11. Review the informed consent section, where you agree to understand the risks and side effects. Initial each point to confirm your understanding.
12. Finally, read and acknowledge the Patient’s Release of Liability section, followed by signing and dating the form.
13. Once completed, save your changes. You have the option to download, print, or share the form as needed.

Complete your Patient Intake Questionnaire online today to take the next step toward your medical cannabis journey.