MASSACHUSETTS / RHODE ISLAND RESIDENT PATIENT RELEASE AND ACKNOWLEDGEMENT

Patient agrees to the release and acknowledgement of services provided by MedWell Health & Wellness, as described in MedWell’s Massachusetts/Rhode Island Resident Patient Release and Acknowledgement.
After viewing the consent form, please press back on your web browser to continue your check-in.
  
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MEDWELL HIPAA NOTICE OF PRIVACY PRACTICES

Patient acknowledges MedWell Health & Wellness will handle their personal information in accordance with HIPAA laws and regulations, as described in MedWell’s MedWell HIPAA Notice of Privacy Practices.
After viewing the consent form, please press back on your web browser to continue your check-in.
  
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FINANCIAL AGREEMENT

Due to high demand, MedWell is requiring all Telemedicine appointments be prepaid in order to reserve your time slot with the provider. $75 of this payment is a NON-REFUNDABLE deposit. If you cancel your appointment with less than 24 hours’ notice, or miss your appointment entirely, you will only be refunded the difference once the $75 deposit is deducted from your original payment. Thank you for understanding and your cooperation in this matter as we work to meet the needs of all current and future Medical Marijuana Patients.
  
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MedWell Billing Agreement

By checking the box below I agree to the terms of MedWells billing agreement. The full version of this agreement can be found here.
  
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Arbitration Agreement

I have read and agreed to the arbitration agreement here.
  
I agree

Waiver of Liability

I have read and agreed to the waiver of liability here.
  
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Text and Email Consent

I have read and agreed to the text and email Consent here.
  
I agree

Required Patient Information

Please provide us with ONLY the last 4 digits of your Social Security number. The Massachusetts CCC will use this along with your Full name and DOB to confirm your Identity during the registration process.
Last 4 of SSN:

Primary Care Doctor

If you have a Primary Care Doctor, please list their name, location, and phone number below.
Primary care provider information:

Previous Medical Marijuana Card Information

Please enter the below information if you have been evaluated for a Medical Marijuana card in the past:
  
Have you ever previously been evaluated for a Medical Marijuana card in any state?
If yes, please elaborate:

Medical History

Please list any medical conditions that you have ever been evaluated for by a physician, admitted to a hospital or are currently being treated for:
    For example:
  • HIV/Aids
  • Hepatitis C
  • Arthritis
  • Cancer
  • Glaucoma
  • Migraine Headaches
  • Weight Loss/Anorexia
  • Severe debilitating chronic pain
  • Neuropathy
  • Severe and persistent muscle spasms including but not limited to those characteristic of Multiple Sclerosis or Crohn’s Disease
  • Seizures
  • Severe Nausea
  • High Blood Pressure
  • Depression
  • Anxiety
  • Insomnia
  • PTSD
  • Heartburn
  • Irritable Bowel Syndrome
  • Chronic Bronchitis
  • Asthma
  • Chronic Allergies
  • Cachexia or wasting syndrome
  • Agitation related to Alzheimer’s Disease
  • Any other diseases affecting the kidneys, liver, nervous system, or bladder.
Please list any current medical conditions:

Past Surgical History

Please list any surgeries that you have had in the past. Include the reason, date, hospital, and doctor who performed the surgery.
Past surgical history:

Review of CURRENT Symptoms

Please list any symptoms that you currently experience that are relevant to your application for a Medical Cannabis card. (For example: chronic pain, anxiety, depression, nausea, insomnia, restlessness, headaches)
Current symptoms:

Medications

Please list your current medications. This should include BOTH over-the-counter medications and prescribed medications.
List of current medications:

Chief Complaint

Please describe the medical condition(s) or complaints that you are seeking a recommendation for medical marijuana.  (How long have you had symptoms/diagnosis?) 
Current medical conditions and complaints:
  
Does this medical condition limit your ability to conduct major life activities? (Work, Eat, Sleep, Interact with others?)
  
Do you feel that if this medical condition is not alleviated, it may cause serious harm to your physical or mental health, and safety?
  
Have you received medical care or evaluation by a physician/specialist for this medical condition?
If not listed already, please describe all treatments that you have received to date for your current medical problems such as the medications prescribed, surgeries, physical therapy, acupuncture, homeopathy, or chiropractic care:
  
Do you currently smoke cigarettes?
If yes, how many packs per week?
  
Do you consume alcohol?
If yes, how often?

Cannabis (Marijuana) History

The following questions pertain to current or past Cannabis (Marijuana) use.
  
Do you currently use cannabis to treat your current medical condition?
  
Does cannabis provide relief for your symptoms?
If yes, please describe (Example: less pain or nausea):
  
How often do you use cannabis?
How much cannabis do you consume per treatment?
  
What method do you currently use most frequently to consume the cannabis?

Additional Information

Please provide any other additional information you believe is relevant to the doctor's evaluation.
Additional information:

Signature

Please sign by typing your name and date of birth.
Your Name:
   
Your DOB: