Patient In-take Form

Be./Citiva New Patient Registration

Please complete the form below. This will register you for all of our NY dispensary locations.
Patient Information
Name - PLEASE USE ALL CAPS *

First Name Middle Name Last Name
Email- PLEASE USE ALL CAPS *
Date of Birth *

Month Day Year
Contact Number: *

Area Code Phone Number
Address - PLEASE USE ALL CAPS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Do you qualify for any of the following? Be./Citiva offers various types of discounts, each with different criteria defining their eligibility. You will be asked to provide documentation. *

Senior Citizen (65+) First Responder/Healthcare Professional Teacher Veteran None of the Above
Please upload identification for above discount application.

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Acceptable forms of documentation include: · First Responders: Official Firefighter/Police/EMS ID cards; · Healthcare Professionals: Healthcare organization ID or other official documentation signifying status; · Teachers: School district-issued staff ID cards; · Veterans: Verify prior military service (current service members are ineligible) using US Department of Defense-issued Common Access Card (military ID), Veteran ID card, Veteran Health ID card, Veteran’s designation on state-issued driver's license or military separation documents (e.g. DD Form 214). Cancel of
Forms of Program Identification
NYS Medical Marijuana Program Registry ID Card Number - PLEASE USE ALL CAPS FOR LETTERS *
Expiration Date *
Please upload an image of the FRONT of your NYS Medical Marijuana Program Registry ID Card *

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Cancel of
Please upload an image of the BACK of your NYS Medical Marijuana Program Registry ID Card *

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Cancel of
Type of Valid ID (License, Passport, etc.) - PLEASE USE ALL CAPS *
ID # on Form - PLEASE USE ALL CAPS FOR LETTERS *
Expiration Date *

Month Day Year
Date
State *
Please upload an image of the FRONT of your ID *

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Cancel of
Qualifying Information
Certifying Practitioner's Last Name - PLEASE USE ALL CAPS *
Please upload an image of the FRONT of your Patient Certification form from your provider. *

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Cancel of
Qualifying Condition - PLEASE USE ALL CAPS *
Pain Scale *

No Pain Mild Pain Moderate Pain Severe Pain Very Severe Pain Worst Possible Pain
List Any Allergies To Medications - PLEASE USE ALL CAPS *
Cannabis Experience *

Naive Cannabis User Experienced Cannabis User
If we need to contact you regarding patient related issues, what is your preferred way to receive communications? *

Email Text Telephone Call None of the above
May we leave a voicemail on the phone # you provided? *

Yes No
May we discuss your information with another party (i.e. Designated Caregiver)? *

Yes No
A Designated Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary. If you feel that you need a caregiver, please contact your certifying physician. YOu will have the opportunity to complete contact information for your Designated Caregiver at the end of this form.
How did you hear about us? *

Website Leafly Weedmaps Google Social Media Referral Doctors Visit
How would you like to receive communications from Be./Citiva regarding promotions, deals, updates, etc.? *

Text and Email Text Only Email only None of the above
By providing your mobile number and signing and submitting this form, you consent to receive recurring informational, marketing and advertising text messages and calls at the number you have provided, including via an automatic telephone dialing system or prerecorded or artificial voice from Citiva, its affiliates, and/or service providers. Consent is not required as a condition of purchasing any goods or services. Message and data rates may apply. Opt-out at any time by replying “STOP”.
Mobile Number for Text Marketing Communications

Area Code Phone Number
Signature for Text Marketing Communications

Clear
Please select the ethnic background with which you most closely identify. Select as many as apply. *

Asian Hispanic/Latino White/Caucasian Black/African American Native Hawaiian/Pacific Islander American Indian/Alaska Native Two or more race I prefer not to answer
Please select your gender. *

Male Female Prefer Not To Answer
Designated Caregiver Information (if applicable)
Name - PLEASE USE ALL CAPS:

First Name Last Name
Relationship - PLEASE USE ALL CAPS
Contact Number

Area Code Phone Number
Caregiver Number
Address - PLEASE USE ALL CAPS

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email - PLEASE USE ALL CAPS
example@example.com

MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT
I understand that it is unlawful to use and possess medical marijuana outside of the State of New York. I further understand that my Medical Marijuana Program Registry ID Card does not allow me to cultivate marijuana for any purpose. Please provide your initials. *
I agree that I will not divert any marijuana to any other person. All medical marijuana I purchase will be for my sole consumption. Please provide your initials *
I agree to use medical marijuana in a manner that fully comports with all relevant New York State laws and regulations, and hereby release and waive all claims against Citiva Medical, LLC d/b/a Be. from any and all liability related to my use of medical marijuana. Please provide your initials *
Please do not sign this agreement if you do not understand the information you have received or are not comfortable with the risks that may be related to the medical use of cannabis.
Patient Name *

First Name Last Name
Patient Signature: *

Clear
Today's Date *

Month Day Year
Date
Type a question
Should be Empty:

Be./Citiva New Patient Registration

MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT