Cannabis Patient Client Intake Form

Create Document

A cannabis patient client intake form is a questionnaire that medical marijuana dispensaries use to gather information about new patients. The form asks for a description of the patient’s medical condition and current symptoms, which helps dispensaries recommend the most appropriate strain, potency, dosage, and methods of cannabis consumption.

Cannabis Patient Client Intake Form

A cannabis patient client intake form is a questionnaire that medical marijuana dispensaries use to gather information about new patients. The form asks for a description of the patient’s medical condition and current symptoms, which helps dispensaries recommend the most appropriate strain, potency, dosage, and methods of cannabis consumption.

Create Document
PDF
Word (.docx)
OpenDocument
PDF
Word (.docx)
OpenDocument

Last updated September 30th, 2024

Document Preview

A cannabis patient client intake form is a questionnaire that medical marijuana dispensaries use to gather information about new patients. The form asks for a description of the patient’s medical condition and current symptoms, which helps dispensaries recommend the most appropriate strain, potency, dosage, and methods of cannabis consumption.

Downloads: 547
  1. Home »
  2. Client Intake Forms »
  3. Cannabis Patient

Qualifying Medical Conditions

In order to legally purchase medical marijuana, patients are generally required to suffer from one of the following conditions:

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

Qualifying conditions for cannabis treatment vary as each state has its own regulations and guidelines.[1]

Required Information

Proof of Eligibility

The patient must provide their medical marijuana (MMJ) card number and the name of the physician who recommended cannabis treatment. This information is necessary to confirm the legitimacy of the request for medical marijuana and ensure compliance with state laws and regulations.

Medical History

  • 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 Treatments – The 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

If the patient has consumed cannabis before, they must describe the positive and negative effects they experienced, their preferred methods of consumption, and their preferred levels of CBD and THC.

Registered Caregiver

If the patient has a registered caregiver, they must provide the name and phone number of the caregiver who will pick up, transport, and administer medical marijuana on their behalf.

Acknowledgment

The patient must review and sign the consent form, indicating that they acknowledge their privacy rights and understand how the dispensary plans to use their protected health information.

Additional Material

In addition to the intake form, dispensaries often provide new patients with the following documents:

  • Notice of Privacy Practices – A document that details policies and procedures about patient privacy and how health information is protected.
  • Consent Forms – These forms outline the potential risks and benefits associated with cannabis use and ask that patients agree to follow the dispensary’s policies and treatment instructions.
  • Educational Material – Pamphlets or brochures offering information on cannabis, including the potential advantages, possible adverse effects, and responsible usage guidelines.
  • Legal Obligations – A form that defines the legal requirements surrounding the substance, such as the maximum possession limit, qualifying medical conditions, and MMJ registration instructions.

Sources

  1. CDC – State Medical Cannabis Laws