First-Time Patient Questionnaire (Form 1 of 3)
Thank you for choosing Vireo Health of New York for your medical cannabis needs. Please fill out this brief questionnaire prior to your consultation. This will allow our Pharmacy team to better assist you.
Patient First Name:
Patient Last Name:
Please enter a valid phone number.
Medical Cannabis ID Number
Please check all those circumstances that apply:
Pregnant or possibly pregnant
Personal or direct family history of mental health conditions such as schizophrenia
Children in home
Do you have any medication or food allergies?
Yes, please specify:
What are the symptoms you would like medical cannabis to relieve?
Muscle Pain / Spasms
Nausea / Vomiting
Have you received any medical cannabis products within the last 30 days?
Please list medications that you are currently taking or any other information you would like our Pharmacy Team to know about:
Upload any relevant files you would like our Pharmacy Team to review:
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Name of Person signing form (if not patient)
Referred By (If You Found Vireo Via A Referral)
Should be Empty: