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 *

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 SclerosisDEPRESSIONARTHRITISGLAUCOMA
Please attach your VALID MAINE STATE ID / DRIVERS LICENSE (temporary MAINE License paperwork is acceptable pictured with your voided out of state or expired license. IF YOU DO NOT HAVE A MAINE STATE LICENSE OR ID YOU ARE NOT ELIGIBLE FOR A MED CARD IN MAINE )*

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WE CANNOT ACCEPT PASSPORTS, MAIL, OR OUT OF STATE LICENSE OR IDS. ONLY MAINE STATE LICENSE OR ID IS ACCEPTABLE FOR A MEDICAL CARD IN MAINE 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 and an email (may go to junk folder). 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.
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

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Payment

VIRTUAL APPLICATION MED CARD$50.00

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Total $0.00

Credit Card

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(VIRTUAL) Beach Health Center Patient Intake Form

Patient Medical History

Patient Agreement & Consent

Credit Card