New Patient Intake Form

First

Goes By (If Different Than First)

Last

Phone

Address

Date of Birth

Gender Identity

State / Territory / District Medical Card Issued By

Medical Card Expiration Date

Name of Recommending Practitioner or Self-Certified

Please upload the following documents (in pdf, jpeg, jpg or png format):

+ Front of Medical Card

+ Back of Medical Card (Only when patient number is on back of card)

+ Front of Government Issued Picture ID

+ Back of Government Issued Picture ID

Note: Back of government ID not applicable for passports

Please verify your age to enter.