RECERTIFICATION INTAKE

************** RECERTIFICATION **********

Dr Sam 420
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 who 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
Birth Date*

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency contact/POA
Occupation (retired, student etc are options)*
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 PREFERRED time for us to call after 10am (MONDAY-FRIDAY) ? We will be calling from (724)257-2157. PLEASE NOTE: WE CLOSE AT 5pm M-Th, and 3pm ON FRIDAY. We will try to accomodate your preferred time (this is not a specific appointment time)
PREFERRED TIME TO CALL*
PREFERRED TIME, NOT AN OFFICIAL APPOINTMENT
We do NOT conduct calls after 430pm M-Th, or after 3pm on Fridays. (WE ARE CLOSED SAT-SUN)
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 and Payment policy. By signing below I agree to follow these policies.
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
I understand payment of $99 is due at the time of the consultation*

YES I UNDERSTAND
Date/Time
Now that you have completed the form, once you click below on "SUBMIT TO DR URICKS OFFICE", we will receive it.
For physician use only:
FOR PHYSICIAN USE ONLY
Electronically Signed by Samuel Urick III, D.O.
Should be Empty:

************** RECERTIFICATION **********

For physician use only:

**** RECERTIFICATION