Personal Information

Let's start with the basics

First Name

Last Name

Date of Birth

Email Address

Mobile Phone

Address & Contact

Your residential information

Street Address

City

State

ZIP Code

Emergency Contact

Qualifying Conditions

Select all that apply to you

Chronic Pain

Persistent discomfort

PTSD

Post-traumatic stress

Anxiety/Depression

Mental health conditions

Cancer

Current or history

Epilepsy/Seizures

Neurological condition

Crohn's/IBS

Gastrointestinal

Glaucoma

Eye pressure condition

Multiple Sclerosis

Autoimmune disease

Other Condition (Optional)

Current Medications

Your medical background

Current Medications

Include dosage if known

Allergies

Primary Physician

Physician Phone

Medical Marijuana History

Previous recommendations

Are you currently a registered MMJ patient?

Yes No

Do you require a caregiver?

Yes No

Preferred Dispensary (Optional)

Identity Verification

Secure document upload

State ID or Driver's License Number

Upload Photo ID (Front)

Click to upload or drag and drop

JPG, PNG up to 10MB

Upload Selfie Photo

Take a photo or upload

Clear face photo required

Consent & Review

Final steps to complete

HIPAA Privacy Consent: I authorize the release of my medical information to Verify MC and associated physicians for the purpose of medical marijuana evaluation.

Telehealth Consent: I consent to telemedicine consultations and understand the risks and benefits of remote healthcare services.

Terms of Service: I agree to the Terms of Service and Privacy Policy of Verify MC.

Digital Signature (Type your full name)

By submitting this form, you certify that all information provided is accurate and complete to the best of your knowledge.

Application Submitted!

Your patient intake form has been successfully submitted. A physician will review your application within 24-48 hours.

Reference ID: VM-2024-78432

Status: Under Review