VIRTUAL Beach Health Center Patient Forms

(VIRTUAL) Beach Health Center Patient Intake Form

- Your personal data privacy is protected through our system compliant with HIPAA. - You must be 18 years old or older with a VALID MAINE STATE LICENSE OR ID. - Virtual APPLICATIONS ARE PROCESSED MONDAY - SATURDAY 10AM - 6PM. - WE ARE CLOSED SUNDAYS- applications submitted on Sundays OR after 6pm on Saturdays will be processed on Monday in the order they were received - You will get a text with a digital medical card within 2 hours (Monday - Saturday), if the form is COMPLETED OUTSIDE THE HOURS OF 10AM - 6PM it will process in the order received during normal hours the next day. -Virtual applications are always $50 there is no tax
Patient LEGAL Name as seen on your ID, please recheck your name for accuracy*

First NameLast Name
Patient Birth Date MM/DD/YYYY*

MonthDayYear
DATE OF BIRTH MM/DD/YYYY*

MonthDayYear
Date
Phone Number - please recheck number for accuracy WE WILL TEXT YOUR DIGITAL CARD TO THE NUMBER YOU PROVIDE, CHECK THE NUMBER *

Area Code - (like 207,518 etc) Phone Number
Mailing Address - your actual mailing address for the physical med card to be sent to*

Street Address

apartment or unit if needed

CityState / Province

Postal / Zip Code
Patient E-Mail*
Patient Medical History
Do you have any of the following conditions/symptoms? (Please check all that apply)*

Anxiety DisorderMuscle crampsNauseaAnorexiaPainPTSDCron's DiseaseFibromyalgiaInsomnia - SLEEPLESSNESSHeadachesCancerSeizuresMultiple SclerosisDEPRESSIONARTHRITISGLAUCOMAOther
Please attach your VALID MAINE STATE DRIVERS LICENSE OR MAINE STATE ISSUED ID. WE ACCEPT PAPER MAINE LICENSE AS WELL (MUST HAVE A VALID ISSUE AND EXPIRATION DATE)*

Browse Files
WE CANNOT ACCEPT PASSPORTS, PASSPORT CARDS, MAIL, REGISTRATIONS, INSURANCE, OUT OF STATE LICENSE OR ANYTHING OTHER THAN THE MAINE STATE LICENSE OR ID. ONLY MAINE STATE LICENSE OR ID IS ACCEPTABLE FOR A MEDICAL CARD IN MAINE. PASSPORTS AND PASSPORT CARDS ARE FEDERAL IDENTIFICATION, CANNABIS IS FEDERALLY ILLEGAL. MAINE MEDICAL PROGRAM IS A STATE PROGRAM AND AS SUCH ONLY A VALID MAINE STATE LICENSE OR ID IS ACCEPTED. IF YOU DO NOT HAVE THAT DO NOT GO ANY FURTHER ON THIS FORM. IF YOU ARE REJECTED DO TO THIS SECTION YOU WILL FORFIT $1.75 (SQUARES PROCESSING FEE) AND IT TAKES 5-7 DAYS TO GET YOUR MONEY BACK FROM SQUARE. IF YOU ARE UNSURE ABOUT WHAT YOU ARE ABOUT TO UPLOAD TEXT US AT 207-229-4492 AND ASK US. Cancelof
Patient Agreement & Consent

* Please sign below that you have read, understood, and answered the above questions truthfully to the best of your knowledge. Please be advised that payment for all services will be taken at the bottom of this form. You will receive a text within 2 hours with your digital med card. Please check your phone number and email address before submission to ensure you get your card in a timely manner.
Please read and check each item:*

I hereby declare that I have truthfully and completely disclosed all information regarding my medical and behavioral health conditions.I understand that Beach Health Center will not send my medical information or card status to anyone unless I send a written request to do soThe Maine Medical Cannabis Program is protected by the medical privacy act. I understand that no one knows I have a Maine Medical Cannabis Card unless I tell them or show them my card. I understand that there is no registry in Maine.I attest that I have attached a valid Maine state license or ID that is in my possession and is not revoked, surrendered, or lost.I understand that applications are processed Monday - Saturday 10am - 6pm with in 2 hours. Submissions after 6pm will be processed the next business day, anything after 6pm on Saturday or anytime Sunday will be processed Monday.I understand that the physical medical card will be mailed to me, there is no pick up available.
Patient Signature*

Clear
Today's Date*

MonthDayYear
Date
How would you like to be notified next year that your renewal is coming due? you may choose more than one

emailmailnone

My Products

VIRTUAL APPLICATION MED CARD On Special from 12.23.24-1.1.25$45.00

Must be 18+. Must have a Maine state license or identification card (temporary paperwork is not acceptable must be a valid card). No medical documentation needed. Nurse Practitioner on site for video call certifications.

Enter coupon

Total $0.00

Credit Card

Digital med cards are valid for use, click the box if you DO NOT WANT YOUR PHYSICAL CARD MAILED AND ONLY WANT THE TEXTED DIGITAL (PICTURED) MED CARD

DO NOT MAIL MY PHYSICAL MED CARD, I ONLY WANT THE DIGITAL CARD THAT IS TEXTED TO MEmail the card to me
IF YOUARE WAITING AT A DISPENSARY, PLEASE LET US KNOW WHAT DISPENSARY YOU ARE AT BELOW (OPTIONAL JUST FOR OUR INFORMATION)
PLEASE NOTE, SUBMISSIONS 6PM OR AFTER ARE PROCESSED THE NEXT DAY. SUBMISSIONS 6PM OR AFTER ON SATURDAYS OR ANYTIME SUNDAY ARE PROCESSED THE FOLLOWING MONDAY
Should be Empty:

(VIRTUAL) Beach Health Center Patient Intake Form

Patient Medical History

Patient Agreement & Consent

Credit Card