Cannabis Patient Client Intake Form

Cannabis Patient Client Intake Form

Last updated July 10th, 2023

  1. Home »
  2. Client Intake Forms »
  3. Cannabis Patient

cannabis patient client intake form is a questionnaire that medical marijuana dispensaries use to gather information about new patients. The questionnaire asks for a description of the patient’s qualifying medical condition and current symptoms, which helps dispensaries recommend the most appropriate strain, potency, dosage, and methods of cannabis consumption. Patients are also required to provide the name of the authorizing physician and their medical marijuana card number as evidence of their eligibility for cannabis treatment.

Qualifying Medical Conditions

In order to legally purchase medical marijuana, patients are generally required to suffer from a terminal or debilitating medical condition, such as:

  • Glaucoma
  • Alzheimer’s disease
  • Crohn’s disease
  • Eating disorders
  • Chronic pain
  • Nausea and vomiting due to cancer treatment

The qualifying conditions for cannabis treatment vary from state to state, as each has its own regulations and guidelines.


Required Intake Information

Patients must supply the following information before or during their initial visit to the medical marijuana dispensary:

Proof of Eligibility

Dispensaries will need to know the name of the physician who recommended cannabis treatment as well as the patient’s medical marijuana (MMJ) card number. This information is necessary to confirm the legitimacy of the request for medical marijuana and ensure compliance with state laws and regulations.

Medical History

The intake form asks for a variety of medical information that will assist the dispensary in providing safe and effective treatment recommendations. This info includes:

  • Qualifying Medical Condition – The medical condition that makes the patient eligible for cannabis treatment.
  • Symptoms – The symptoms the patient experiences from their medical condition, including the frequency, severity, and duration.
  • Past TreatmentsThe type, duration, and results of treatments already attempted.
  • Medications – The names of any prescription medications the patient takes, including dosage and frequency.

Consumption Preferences & Side Effects

Patients who’ve previously consumed cannabis will be requested to describe the positive or negative effects they experienced, their preferred methods of consumption, and their preferred levels of CBD and THC.

Registered Caregiver

Some patients may be unable to collect medical marijuana at the dispensary personally. If this is the case, the patient must provide the name and phone number of their registered caregiver, which is an individual they’ve selected to pick up, transport, and administer medical marijuana on their behalf.


The intake form includes an acknowledgment section for the patient to review and sign, indicating their understanding of their privacy rights and awareness of how the dispensary plans to use their protected health information.

Additional Documents

In addition to the intake form, dispensaries should also provide new patients with the following paperwork:

  • Notice of Privacy Practices – A document that details policies and procedures about patient privacy and the management of protected health information.
  • Consent Forms – Forms that acknowledge the potential risks and benefits associated with cannabis use and indicate the patient’s agreement to follow the dispensary’s policies and treatment instructions.
  • Educational Material – Pamphlets or brochures offering information on cannabis, including its potential advantages, possible adverse effects, and responsible usage guidelines.
  • Legal Obligations – Details about legal requirements, such as the maximum carryable amount, qualifying medical conditions, and MMJ registration instructions.