New Patient Intake Forms

For New Patients and Recertification

Patient Name:

Date Of Birth:

Gender:

Contact Phone Number:

E-mail Address:

Physical Address:

New Patient or Recertification?

MMCC Patient ID Number:

MMCC Card Expiration Date (Printed on your patient ID card)

Occupation (If Applicable)

Primary Care Provider (If Applicable)

Referred by (If Applicable)

Past Medical History

Taking any medications, currently?

Reasons for Cannabis Use

If yes, please list it here

Have you every had surgery?

If yes, please list surgical history here

Do you agree to follow all MMCC Rules and Regulations and HIPAA guidelines?