Patient Name

Date Of Birth

Address

MMJ Card/MMCC ID

Exp.Date

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Driver’s License

Exp.Date

Home Phone

Cell Phone

Email

Primary Care Physician

Registered Caregiver (if applicable) A Registered Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary

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Are you a veteran? (please check one)

yes

no

If yes, please provide documentation.

Qualifying Condition: (please check one)

Anorexia

Post-Traumatic Stress Disorder (PTSD)

Cachexia

Severe nausea

Cancer

Severe or persistent muscle spasms

Chronic Pain

Severe pain

Wasting Syndrome

Positive Status for Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS)

• Other medical condition which is severe and for which other treatment have been ineffective:_____

Please check one:

- Tobacco Use?

yes

- Alcohol Use?

yes

- Cannabis Usage?

yes

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PRIVACY POLICY AND PRACTICES

As a patient of MyHealth LLC:

I understand I have rights to privacy of my protected health information as defined by the Health Insurance Portability Act of 1996.

I have been made aware that upon request a copy of MyHealth LLC’s privacy policy is available to me.

MyHealth LLC has made me aware of their right to change the terms of its Notice of Privacy Practice.

Accept Privacy Policy And Practice Note: checking this box means that you have agreed to privacy policy and practice of MyHealth LLc

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