• PATIENT INTAKE AND MEDICAL HISTORY FORM

    DR SAM 420
  • FOR INDIVIDUALS WHO ARE PENNSYLVANIA RESIDENTS AGE 18 AND OLDER 

    IF YOU ARE UNDER 18, PLEASE STOP HERE.   

     

    • Payment for the consultation with Dr. Sam is due at the time of the scheduled consultation.

     

    • Some employers may ask for proof that you can work safely when using medical marijuana.  We can acknowledge that you are certified but cannot give a time frame for them on how long the THC will remain in your system or what effect it will have on impairement (just as we cannot commment on how long a medication like ativan or xanax (benzodiazepines) can impair you).

    • WHEN COMPLETING THE FORM, YOU WILL NEED TO FILL IN EACH FIELD MARKED BY AN ASTERISK *.  Your submission is completed if a screen pops up after submission stating "THANK YOU FOR YOUR SUBMISSION" with a GREEN CHECK MARK.

     

     

  •  - -Pick a Date
  • Patient Information

  •  / /Pick a Date
  • ADDRESS MUST Match PA Driver License/Photo ID card - WHATEVER PENNDOT has on file for your address
  •  -
  • Reason for Medical Marijuana Evaluation

  • MEDICAL HISTORY (If doing on cell phone, turn phone sideways for this section!!)

    We need to know a bit about your medical conditions, any doctors or specialists that you see, and surgeries that you may have had.
  • SOCIAL HISTORY

    This helps to better understand you and your answers do NOT disqualify you from becoming a medical marijuana patient.
  • ANXIETY (GAD-7 Questionnaire) - for those with anxiety

    ' OVER THE PAST TWO WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY THE FOLLOWING: (make sure to answer each question with a red * mark before you click "SUBMIT" below)
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  • CONSENT FOR TREATMENT AND MEDICAL CANNABIS USE

  • I am being evaluated for a physician's recommendation for Medical Cannabis. The physician will make recertification and recommendation based, in part, on the medical information I have provided. I hereby acknowledge that I have not misrepresented my medical condition to obtain this recommendation and it is my intent to use Medical Cannabis only as needed for the treatment of my medical condition, not for recreational or non- medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of Medical Cannabis. I have been informed of and understand the following.

  • THANK YOU FOR COMPLETING THIS INTAKE FORM. 

    When you click "SUBMIT" below, this will be transmitted to our office

     ****NEXT STEPS****

     

    REGISTER WITH THE STATE TO GET YOUR PATIENT ID NUMBER!!!  After submitting this form you can return to drsam420.com/scheduling to complete Step 2 and register with the state.

     

     YOU WILL NEED TO PAY AT THE TIME OF YOUR CONSULTATION.  If you are unable, please let Dr. Urick know so that we can schedule you for your telemed/phone consultation at a later date (office@drsam420.com)

  • WHEN YOU PRESS "SUBMIT" BELOW, IF YOU DID NOT COMPLETE FIELDS WITH A RED ASTERISK * , THE FORM WILL NOT GO THROUGH.

     

    If you do not receive a pop-up message stating "THANK YOU FOR YOUR SUBMISSION" or a confirmation email, then it did not go through.

                     

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  • FOR PHYSICIAN USE ONLY BELOW

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