Patient In-take Form

New Patient Registration: Mayflower Medicinals

Please complete the form below
Name *

First Name Middle Name Last Name
Email *
example@example.com
Date of Birth *

Month Day Year
Contact Number: *

Area Code Phone Number
What type of phone number is this? *

Mobile Home Work
If Mayflower Medicinals, Inc needs to contact you for patient-related reasons, what is your preferred way to receive communications? *

Email Text Telephone Call
May we leave a voicemail on the phone number you provided above? *

Yes No
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
MMJ Card Number *
Expiration Date *
Please upload an image of your MMJ card *

Browse Files

Cancel of
Type of Valid ID (License, Passport, etc.)
ID # or Passport # *
Expiration Date *

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

Browse Files

Cancel of
May we discuss your information with another party? (i.e. Registered Caregiver)

Yes No
A Registered 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. If you have a Registered Caregiver, please complete their information in the below fields.
Registered Caregiver Name:

First Name Last Name
Relationship
Caregiver Contact Number

Area Code Phone Number
Caregiver Number
Caregiver Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Caregiver Email
example@example.com
How did you hear about Mayflower Medicinals, Inc? *

Google or Other Search Engine Leafly Weedmaps Social Media Patient Referral Mayflower Website Doctors Visit
Would you like to receive marketing communications from Mayflower Medicinals, Inc regarding promotions, new products, events, closing and other updates? *

Yes, Text and Email Yes, Text Only Yes, Email Only No, Neither Text or Email
Please provide the mobile number for marketing & advertising text messages (if applicable)

Area Code Phone Number
By providing your mobile number and signing the below field, you consent to receive marketing and advertising text messages and calls, including via an automatic telephone dialing system or prerecorded or artificial voice from Mayflower Medicinals, Inc., 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”.

I understand
Signature for Marketing and Advertising Text 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
MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT

Please initial the statements below.
I understand that it is unlawful to use and possess medical marijuana outside of the State of Massachusetts. I understand that my registration card does not allow me to cultivate marijuana for any purpose unless I have applied for and received a Hardship Cultivation License. Please input 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. I agree that I will bring any unwanted or unconsumed marijuana to a Registered Marijuana Dispensary for disposal. Please input your initials. *
I acknowledge that I can access to the Mayflower Medicinals' Patient Education Guide. by downloading it from www.mayflowermedicinals.com or obtaining it in store. Please input your initials. *
I understand that marijuana has not been analyzed or approved by the FDA and that medical cannabis may contain unknown quantities of active ingredients, impurities or contaminants. Please input your initials. *
I understand that marijuana has not been analyzed or approved by the FDA and that medical cannabis may contain unknown quantities of active ingredients, impurities or contaminants. Please input your initials. *
I understand that the efficacy and potency of cannabis may vary widely depending on the cannabis strain and ingestion method. Please input your initials. *
I understand that marijuana consumption during pregnancy and breastfeeding may pose potential harms. Please input your initials. *
I understand that driving under the influence of Marijuana is prohibited by M.G.L c. 90, s. 24, and machinery should not be operated Please input your initials. *
I agree to not bring a weapon, or anything that can be used as a weapon to a Mayflower Medicinals, Inc facility. Please input your initials. *
I agree to abide by Massachusetts Law in regard to my use of medical marijuana, and hereby release and waive all claims against Mayflower Medicinals from any and all liability related to my use of medical marijuana. Please input your initials. *
Please do not sign this agreement if you do not understand the information you have received or not comfortable with the risks that may be related to cannabis use or possession.
Patient Name *

First Name Last Name
Patient Signature: *

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Today's Date *

Month Day Year
Date
Should be Empty:

New Patient Registration: Mayflower Medicinals

MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT