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BENEFITS OF MEDICAL CANNABIS
RENEWING PATIENT APPOINTMENTS
Date of Birth
Please list your qualifying medical condition(s) for medical marijuana use:
Please list your current medications (prescription and/or OTC)
How did you hear about The Healing Center Medical Clinic (THCMC)?
Are you now or have you ever been employed by any city, state or federal government department?
If yes, please explain:
I understand that the physician may be contacted to verify and/or authorize my status as their patient as well as any prescription and/or recommendation that may or may not be issued by them. By signing below, I hereby authorize the physician and /or THCMC to make such verifications or authorizations. My signature below shall serve as a release for this purpose only and shall not serve as a waiver of my other patient and physician privacy rights as detailed under Florida and Federal HIPAA regulations. I understand if the physician requests medical records, follow-up appointments, prescription medications or anything else pertaining to my medical marijuana recommendation, my recommendation will become null and void if the the request is not fulfilled within 30 days. I understand that I am not legal to use medical marijuana until I mail my state application to Juneau and receive my Medical Marijuana Registry Patient Card. I understand that I must see my MMJ doctor once a year. By signing below, I agree that if, for any reason I need a replacement of my original Physician's Statement, I will pay a clerical fee of $75 if it has been longer than 30 days since my appointment.
I hereby designate Dr. John McGroarty as my Primary Care Physician.
IF YOU DO NOT HEAR FROM US WITHIN 48 HOURS AFTER SUBMITTING THE FORM, PLEASE GIVE US A CALL AT 786-353-8375
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Copyright © 2017 Paradise Valley Cannabis Company. ***NOTICE: Marijuana remains illegal to cultivate and posses under Federal Law. We are a HIPPA compliant company. We will never sell or distribute any patient information. Records are kept securely at our Montana location.