RECERTIFICATION INTAKE

ATTENTION

If you have NEVER been certified for a card in Pennsyvania, please go back to drsam420.com and complete Step 1 - PATIENT INTAKE FORM

This form is for those whom have already been certified in the state

The Recertification consultation fee is due to Dr Sam at the time of the consultation

Name*

First NameLast Name

Date of Birth*

MonthDayYear

Today's Date

Date

Phone Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Emergency contact/POA

How did you hear about us/Dr Sam 420 ?

Condition(s) you were initially certified for*

Any medications you are currently taking ?*

How has medical cannabis/medical marijuana been working for you? *

When is a good time to call to schedule (MONDAY-FRIDAY) ? We will be calling from (724)257-2157. Texts come from 724-257-2178

BEFORE RENEWING YOUR CARD, make sure your address with the Pennsylvania Medical Marijuana Program is up to date. If you have moved, you MUST update your address with PENNDOT for Driver's license or State ID cards.

If you DO NOT update your address with PENNDOT AND the DEPT OF HEALTH MARIJUANA PROGRAM, they will mail the card to the OLD address.

If you are locked out of your PA Medical Marijuana account, please call 888-733-5595 and they can unlock it for you.

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.

SEE PDF FORM - 3 pages - below and read them. At the bottom of this form you will sign to acknowledge that you understand these terms of consent.

I, the undersigned, acknowledge that I have read the Release of Liability and Acknowlegements, Agreements, Disclosures and Informed Consent. By signing below I agree to follow these policies.

IF YOU NEVER CERTIFIED WITH DR URICK BEFORE, MAKE SURE TO FILL OUT THE "PATIENT INTAKE FORM" found on this website under the "SCHEDULING" Tab.

By typing your full name here, you are giving your consent to the above forms and this serves as your legal signature.*

TYPE FULL NAME TO SERVE AS YOUR SIGNATURE

Date/Time

I understand that when I have the over the phone consultation with Dr Sam, the payment for the consultation will be due at that time - paid by debit/credit/HSA/ debit gift card.*

YES I UNDERSTAND

Now that you have completed the form, once you click below on "SUBMIT TO DR URICKS OFFICE", we will receive it.

You will receive a phone call from our office: 724-257-2157 (it shows up as a tarentum number). We want you to know so you do not think it is a spam caller.

Once this form is submitted, we will contact you to find time to speak on the phone for your recertification.

The payment for Dr Urick to recertify you is due to our office at the time of the scheduled call (via debit/credit/HSA card).

Click "SUBMIT" Above to send this to our office. If it doesnt submit, you may need to make sure you have completed all required fields with a red (*)

FOR PHYSICIAN USE ONLY

Electronically Signed by Samuel Urick III, D.O.

RECERTIFICATION

For physician use only: