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ID Card | Patient Name | Date of Birth | Email | Phone | How has medical marijuana helped alleviate your symptoms? | Any negative side effects or adverse reactions | Leave prescription as is or need to contact? | Patient Records | Entry Date |
|---|---|---|---|---|---|---|---|---|---|
 | Dalton Vieitas | 7/5/1980 | daltonvieitas@gmail.com | +15616760055 | Yes | No | Leave the same, no further action needed | May 21, 2025 | |
 | Jeffrey Hoshor | 5/17/1962 | jeffrey.hoshor@gmail.com | +15618535285 | Anxiety level is much less | No | Leave the same, no further action needed | January 18, 2025 | |
 | Alex Shlamowitz | 2/28/1997 | alexshlamowitz@gmail.com | +15617973211 | Request Doctor to contact me to make changes | September 20, 2023 | |||
 | Barry Pugatch | 9/8/1945 | bpugatch@pugatch.com | +15164581624 | Leave the same, no further action needed | September 22, 2023 | |||
 | Dalton Vieitas | 7/5/1980 | daltovieitas@gmail.com | +15616760055 | Leave the same, no further action needed | September 26, 2023 | |||
 | Michelle Piano | 11/28/1967 | mdpiano@verizon.net | +19738184730 | Leave the same, no further action needed | September 26, 2023 | |||
 | Sean Marconis | 7/18/1987 | justsean718@gmail.com | +15614414399 | Leave the same, no further action needed | September 27, 2023 | |||
 | Walter Butler | 10/30/1946 | walterbutlermd@yahoo.com | +15028023018 | Leave the same, no further action needed | September 27, 2023 | |||
 | Michaelanne Griffiths-Drysdale | 2/10/1994 | mgriffiths@live.com | +13404740513 | Request Doctor to contact me to make changes | September 28, 2023 | |||
 | michael Dombrowsky | 3/7/1955 | mikedombrowsky@bellsouth.net | +15616286642 | Leave the same, no further action needed | October 2, 2023 | |||
 | Dana Berkowitz | 9/20/1968 | daynadoll0402@yahoo.com | +13058076137 | Request Doctor to contact me to make changes | October 3, 2023 | |||
 | Brenda Blaustien | 8/11/1949 | newyorkbrenda@gmail.com | +19174461964 | Leave the same, no further action needed | October 3, 2023 | |||
 | Kristine Flynn | 5/9/1973 | reolflynn@gmail.com | +15612528953 | Leave the same, no further action needed | October 3, 2023 | |||
 | Kristiaan Ward | 5/9/1978 | kris@adventureparkinsure.com | +15614195639 | Leave the same, no further action needed | October 5, 2023 | |||
 | Jordan Jackson | 11/6/1998 | jjacksonprime5@gmail.com | +15615962439 | Leave the same, no further action needed | October 5, 2023 | |||
 | jeffrey orenstein | 10/5/1947 | jeffreyinnyc@gmail.com | +19172870000 | Leave the same, no further action needed | October 6, 2023 | |||
 | Cory Bonspille | 3/2/1981 | cbonspille@hotmail.com | +15613127928 | Leave the same, no further action needed | October 9, 2023 | |||
 | Eldar Cohen | 6/3/1986 | ecohen86@gmail.com | +19175674475 | Leave the same, no further action needed | October 12, 2023 | |||
 | Makia Santiago | 7/30/1981 | sunfirehookahs@gmail.com | +12167049672 | Leave the same, no further action needed | October 13, 2023 | |||
 | Judith Sady | 8/4/1954 | jsady1@comcast.net | +16099704615 | Leave the same, no further action needed | October 14, 2023 | |||
 | Craig Sawyer | 3/29/1961 | c.sawyer65@yahoo.com | +17729131347 | Leave the same, no further action needed | October 15, 2023 | |||
 | Michelle Pedersen | 8/5/1964 | boutarisister@yahoo.com | +15613517666 | Leave the same, no further action needed | October 15, 2023 | |||
 | Pamela Dabah | 9/3/1954 | pameladabah@gmail.com | +19734793385 | Leave the same, no further action needed | October 16, 2023 | |||
 | Bradley Escalante | 6/15/2003 | smar7y14@gmail.com | +15612487757 | Leave the same, no further action needed | October 17, 2023 | |||
 | Michele Lomonte-mccarrick | 7/12/1980 | miowtc@aol.com | +19546559242 | Leave the same, no further action needed | October 19, 2023 |
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Patient Renewal Forms
ID Card | Patient Name | Date of Birth | Email | Phone | How has medical marijuana helped alleviate your symptoms? | Any negative side effects or adverse reactions | Leave prescription as is or need to contact? | Patient Records | Entry Date |
|---|---|---|---|---|---|---|---|---|---|
 | Laura Winston | 9/13/1962 | laurafromfl@yahoo.com | +15613864743 | Sleep and reduces anxiety I care for my elderly mother | No | Leave the same, no further action needed | November 11, 2024 | |
 | Georgiana Forker | 5/4/1950 | gforker12@gmail.com | +15165216130 | Takes pain away Helps with ulcerative colitis And IBS | No | Leave the same, no further action needed | July 29, 2024 | |
 | Frank Romeo | 11/24/1963 | frankmoble2@gmail.com | +15613507945 | Yes | No | Leave the same, no further action needed | December 28, 2024 | |
 | Kevin Forker | 1/9/1959 | kf3947@msn.com | +15165216129 | Allieviates pain calms anxiety relaxes eye | No | Leave the same, no further action needed | July 29, 2024 | |
 | David Beattie | 5/23/1982 | btconchltl@aol.com | +15612898040 | Helps me sleep a lot better, also less depressed. | no. | Leave the same, no further action needed | August 16, 2024 | |
 | Judith Jacobs | 12/7/1956 | dancejj111@aol.com | +15617194250 | Helps with Pain anxiety | No | Leave the same, no further action needed | January 12, 2025 | |
 | Ryan Thomas | 11/9/1970 | rthomas@thomaseg.com | +15616621410 | Relieves pain and anxiety | No | Leave the same, no further action needed | November 18, 2025 | |
 | Michael Berez | 1/30/1979 | michaelberez@gmail.com | +19172392916 | Yes I’ve been able to manage anxiety | No | Leave the same, no further action needed | October 30, 2024 | |
 | Nathan Lang | 7/13/2007 | nathancorbettlang@yahoo.com | +13392369204 | Relaxes me | No | Leave the same, no further action needed | June 8, 2026 | |
 | Ryan Almeida | 6/22/1992 | ryanalmeida2010@hotmail.com | +15085259717 | It helps with pain, allowing me to eat. Helps alleviate bouts of dread an hopelessness. | No | Leave the same, no further action needed | September 25, 2024 | |
 | Alistair Wilgress-Pipe | 9/6/1997 | alistairwp@aol.com | +17247993677 | Leave the same, no further action needed | November 29, 2023 | |||
 | Vincent Montalbano | 10/13/1990 | shady4lyfe1@yahoo.com | +19542536411 | Helped me manage day to day and be a better mood. | No negative | Leave the same, no further action needed | August 22, 2024 | |
 | Angela Thompson | 3/8/1981 | angelaallen123@yahoo.com | +15618172315 | Pain anxiety sleep nightmares | None | Leave the same, no further action needed | December 18, 2024 | |
 | Michael Kaplan | 4/1/1962 | kaplan.mike@gmail.com | +15187634000 | Calms me down reduces stress Alleviates Pain | No | Leave the same, no further action needed | October 26, 2024 | |
 | Olivia Katz | 11/23/2003 | oliviakatz03@gmail.com | +15618841334 | Calms me down helps sleeo | No | Leave the same, no further action needed,Request Doctor to contact me to make changes | October 28, 2025 | |
 | Mark Noell | 2/18/1955 | mnoell@1050caw.com | +15612398519 | Helps with pain | No | Leave the same, no further action needed | May 27, 2026 | |
 | Thai Tran | 9/28/1968 | ttrant3064@gmail.com | +17542616816 | Uplifts me | No | Leave the same, no further action needed | August 12, 2024 | |
 | Amanda Lawhorne | 5/14/1985 | a.ehrlich0@gmail.com | +15614002377 | Yes. Cannabis helps keep my UC in remission | No | Request Doctor to contact me to make changes | September 4, 2024 | |
 | Debbie Brown | 1/13/1976 | debbrown3506@me.com | +13059844404 | I prefer a natural method for dealing with my health issues and have been to school and earned a certification in cannabis medicine and healthcare | No | Leave the same, no further action needed | December 5, 2024 | |
 | Chaim Nissel | 12/12/1983 | cnissel100@gmail.com | +17189094124 | Pain and peas symptoms | No | Leave the same, no further action needed | November 27, 2024 | |
 | Deborah Korash | 3/4/1948 | deborahk33496@yahoo.com | +15612125266 | Helps me sleep Calms me Pain relief | No | Leave the same, no further action needed | November 6, 2024 | |
 | Victor Maia | 1/30/1982 | victor.maia@live.com | +15616132846 | Helped me sleep and improved my anxiety and depression tremendously. | None. | Leave the same, no further action needed | July 19, 2024 | |
 | Jarrod Levins | 9/27/1982 | jarrodlevins@gmail.com | +15613504764 | Calms me | No | Leave the same, no further action needed | September 10, 2024 | |
 | Christina Cavallo | 7/18/1983 | christina.canterburyshades@gmail.com | +15613972261 | Relaxes me uplifts me | No | Leave the same, no further action needed | October 10, 2024 | |
 | Harry Metrano | 7/27/1984 | 99metrano@gmail.com | +13109220974 | Calming | No | Leave the same, no further action needed | May 8, 2025 |
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