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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 |
|---|---|---|---|---|---|---|---|---|---|
 | Frank Filatro | 3/18/1968 | frankvf@msn.com | +19176700023 | Leave the same, no further action needed | November 25, 2023 | |||
 | Dominic Teresi | 3/4/1995 | dominicteresi21@gmail.com | +15615310089 | Leave the same, no further action needed | July 6, 2024 | |||
 | April A Sherman Rozales | 5/17/1973 | april84567@gmail.com | +15616741371 | Helps with everything pain, anxiety, depression | No | Leave the same, no further action needed | December 13, 2024 | |
 | Jeffrey Hoshor | 5/17/1962 | jeffrey.hoshor@gmail.com | +15618535285 | Leave the same, no further action needed | June 26, 2024 | |||
 | Kristine Flynn | 5/9/1973 | reokflynn@gmail.com | +15612528953 | Pain relief and anxiety | No | Leave the same, no further action needed | November 29, 2024 | |
 | John Clark | 10/16/1963 | radhead@sbcglobal.net | +15618668806 | Leave the same, no further action needed | December 4, 2023 | |||
 | Bruce Humphreys | 10/2/1962 | brucehumphreys13@gmail.com | +15617162180 | Pain and anxiety | No | Leave the same, no further action needed | December 30, 2024 | |
 | Susan Baltrus | 5/10/1963 | sbaltrus@comcast.net | +17813633999 | Helps with pain and sleep | No | Leave the same, no further action needed | August 16, 2024 | |
 | Anna Olivares | 8/2/1983 | annaolivares83@gmail.com | +15615426425 | Leave the same, no further action needed | October 13, 2023 | |||
 | Dana Berkowitz | 9/20/1968 | daynadoll0402@yahoo.com | +13058076137 | Relaxes me before bed | No | Leave the same, no further action needed | December 17, 2024 | |
 | Robert Getsoff | 6/4/1952 | getsoffb@gmail.com | +19176899426 | Request Doctor to contact me to make changes | November 9, 2023 | |||
 | Eldar Cohen | 6/3/1986 | ecohen86@gmail.com | +19175674475 | Sleep thoughts relaxes me | No | Leave the same, no further action needed | December 30, 2024 | |
 | Anthony Restaino | 11/2/1988 | a.restiano62@gmail.com | +15618897210 | Calms me down | No | Leave the same, no further action needed,Request Doctor to contact me to make changes | May 20, 2026 | |
 | Cerefino Orozco | 10/11/1974 | ceferinoorozco@gmail.com | +15615728702 | beneficial | have not | Leave the same, no further action needed | August 4, 2025 | |
 | Lee Miller | 10/18/1953 | dutchandnancy@aol.com | +17209987833 | Pain relief | No | Leave the same, no further action needed | May 18, 2026 | |
 | Jesse Alexander | 12/29/2003 | jessealex03@gmail.com | +19545013512 | Leave the same, no further action needed | May 23, 2024 | |||
 | Eliza Maiorino | 7/17/1980 | elizamaiorino@gmail.com | +15617811556 | Anxiety reduction | No | Leave the same, no further action needed | May 15, 2026 | |
 | kimberley kangos | 12/8/1968 | kkangos@msn.com | +16175103862 | Leave the same, no further action needed | November 3, 2023 | |||
 | Dimitris Tourtounis | 11/6/1984 | d.tourtounis@gmail.com | +12015635002 | Leave the same, no further action needed | December 18, 2023 | |||
 | Julie Cheimets | 9/9/1965 | julie.cheimets@gmail.com | +19788288300 | Used MA just use gummies Just edibles | No | Leave the same, no further action needed | November 7, 2024 | |
 | Kenneth Chapman | 8/12/1975 | kchap2828@gmail.com | +19545981155 | Assists with pain | No | Leave the same, no further action needed | April 21, 2026 | |
 | Michael Hicks | 4/27/1969 | elevatormanmichael@hotmail.com | +13054097593 | Relieves arthritic pain | No | Leave the same, no further action needed | September 2, 2025 | |
 | Michele LoMonte-McCarrick | 7/12/1980 | miowtc@aol.com | +19546559242 | It makes the days easy | No | Leave the same, no further action needed | April 13, 2026 | |
 | Robert Mondry | 1/19/1970 | robertmondry1970@gmail.com | +15616030060 | Sleeping much better, edibles help where smoking is inappropriate | Sativa gives me anxiety | Request Doctor to contact me to make changes | September 7, 2024 | |
 | Jason Silberstein | 4/14/1968 | jasonsilbers@gmail.com | +15617066276 | Pain relief helps with sleep | No | Leave the same, no further action needed | January 3, 2025 |
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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 |
|---|---|---|---|---|---|---|---|---|---|
 | Alex Shlamowitz | 2/28/1997 | alexshlamowitz@gmail.com | +15617973211 | Request Doctor to contact me to make changes | September 21, 2023 | |||
 | Warren Seeley | 11/13/1954 | kote599@protonmail.com | +19084327705 | Leave the same, no further action needed | September 21, 2023 | |||
 | Mary Day | 4/2/1963 | mcday96@yahoo.com | +19782700527 | Leave the same, no further action needed | September 21, 2023 | |||
 | Bianca Brodeur | 6/30/1992 | biancabrodeur@icloud.com | +15615709736 | Request Doctor to contact me to make changes | September 21, 2023 | |||
 | Brenda Deluca | 11/28/1961 | belledujour61@gmail.com | +16789833334 | Leave the same, no further action needed | September 21, 2023 | |||
 | Pablo Solorzano Cohen | 9/10/1977 | psolorzano@gmail.com | +13106213509 | Leave the same, no further action needed | September 23, 2023 | |||
 | Chaim Nissel | 12/12/1983 | cnissel100@gmail.com | +17189094124 | Leave the same, no further action needed | September 24, 2023 | |||
 | Judith Smith | 3/1/1945 | smithrj426@aol.com | +19176126092 | Leave the same, no further action needed | September 26, 2023 | |||
 | Aria Hukki | 11/28/1953 | aria2811@hotmail.com | +15615429548 | Request Doctor to contact me to make changes | September 26, 2023 | |||
 | Venetia Tully | 9/25/1969 | veech47@gmail.com | +15614798171 | Leave the same, no further action needed | September 26, 2023 | |||
 | David Kornhauser | 6/27/1969 | davidkornhauser@yahoo.com | +16464837660 | Leave the same, no further action needed | September 27, 2023 | |||
 | Taylor Sweet | 4/1/1999 | rusweet99@hotmail.com | +19548260598 | Leave the same, no further action needed | September 28, 2023 | |||
 | Ken Volpp | 10/17/1972 | volpp@yahoo.com | +15612844299 | Leave the same, no further action needed | September 29, 2023 | |||
 | Nelly Bronnberg | 6/24/1977 | nbronnberg@gmail.com | +19177214476 | Leave the same, no further action needed | October 1, 2023 | |||
 | Rebecca Garver | 2/10/1962 | kbellaluna@verizon.net | +14124919215 | Leave the same, no further action needed,Request Doctor to contact me to make changes | October 2, 2023 | |||
 | Dan Johnson | 1/17/1994 | danieldjohnson94@gmail.com | +19548924110 | Leave the same, no further action needed | October 2, 2023 | |||
 | Barrie Millen | 5/5/1972 | bmillen20817@gmail.com | +15614008490 | Leave the same, no further action needed | October 2, 2023 | |||
 | Gary Malisos | 6/28/1976 | garymalisos@gmail.com | +19545484071 | Leave the same, no further action needed | October 5, 2023 | |||
 | Coy Dixon | 6/18/1964 | dciii3@bellsouth.net | +15612396758 | Leave the same, no further action needed | October 6, 2023 | |||
 | Amy Graham | 1/30/1958 | amygraham130@gmail.com | +17722918206 | Leave the same, no further action needed | October 10, 2023 | |||
 | Justin Weissfield | 6/1/1975 | jweissfield@gmail.com | +19547787221 | Request Doctor to contact me to make changes | October 10, 2023 | |||
 | Marc Freeman | 5/12/1963 | marcbfreeman@gmail.com | +15164104542 | Leave the same, no further action needed | October 10, 2023 | |||
 | Earl Sands | 5/21/1963 | michaelsands9mm@gmail.com | +19544059108 | Leave the same, no further action needed | October 10, 2023 | |||
 | William Leswing | 2/21/1975 | williamleswing@yahoo.com | +15618664671 | Leave the same, no further action needed | October 11, 2023 | |||
 | Michael Laufer | 1/28/1977 | mike@recruithook.com | +18453139072 | Leave the same, no further action needed | October 11, 2023 |
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