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* 1. Name (First, Middle, Last):

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* 2. Birthday: 

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* 3. Email: 

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* 4. Phone: 

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* 5. Address: 

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* 6. Referred by: 

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* 7. Primary Care Provider:

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* 8. Specialty Care Provider (i.e. neurologist; oncologist; psychologist):

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* 9. Preexisting Qualifying Condition: (Please select all that apply.)

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* 10. Medical History:  (Please select all that apply.)

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* 11. Surgeries/Accidents:

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* 12. Allergies:

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* 13. Medications:  (Please select all that apply.)

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* 14. List other Medications:

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* 15. Alternative Care Providers/Therapies:  (Please select all that apply.)

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* 16. Any Other Health Related Information:

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* 17. Will you be applying for a Care Taker Certificate: If YES, please upload your Caretaker ID and Signed forms to the Dept of Health Website.

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* 18. Will you be applying for a grow-site: If YES, please upload your Marked and Signed forms to the Dept of Health Website.

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* 19. Do you have any other comments, questions, or concerns?

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* 20. Patient Electronic Signature:

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* 21. Provider Signature and verification of Information Provided:

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