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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 |
|---|---|---|---|---|---|---|---|---|---|
 | Andrew Chavkin | 5/31/1947 | amchavkin@gmail.com | +19737695955 | Leave the same, no further action needed | February 12, 2024 | |||
 | Stephen Scott | 3/13/1969 | stephenhscottpiano@gmail.com | +19293166182 | Leave the same, no further action needed | February 14, 2024 | |||
 | Gary Kesler | 1/31/1979 | garykesler@icloud.com | +15613976885 | Leave the same, no further action needed | February 15, 2024 | |||
 | Mari Mishaan | 12/2/1969 | pinkribbon2009@aol.com | +17069700171 | Leave the same, no further action needed | February 15, 2024 | |||
 | Jordan Herbert | 5/8/1986 | jordantherbert@gmail.com | +18106020912 | Request Doctor to contact me to make changes | February 21, 2024 | |||
 | Guillermo Carrillo | 7/11/2002 | guillermoc10807@gmail.com | +15615314239 | Leave the same, no further action needed | February 26, 2024 | |||
 | Joshua Miller | 3/22/2002 | josh7025250@gmail.com | +15617025250 | Leave the same, no further action needed | February 26, 2024 | |||
 | Erica Ansley | 4/14/1983 | ericahp@outlook.com | +19546583747 | Request Doctor to contact me to make changes | February 29, 2024 | |||
 | Tammy Weeden | 11/26/1961 | justtammymae@gmail.com | +12035430980 | Leave the same, no further action needed | February 29, 2024 | |||
 | Katerine Trejo | 5/23/1996 | vannykaty@yahoo.com | +15615137038 | Leave the same, no further action needed | March 2, 2024 | |||
 | Mark Gerbush | 3/13/1956 | markg200fifth@gmail.com | +19173786461 | Leave the same, no further action needed | March 12, 2024 | |||
 | Alyse Smith | 1/2/1990 | alyseksmith@gmail.com | +16092765892 | Leave the same, no further action needed | March 13, 2024 | |||
 | Meredith Steinhaus | 12/13/1972 | meredith.steinhaus@gmail.com | +16469837867 | Leave the same, no further action needed | March 14, 2024 | |||
 | Peter Martz | 6/9/1981 | petergmartz@outlook.com | +13025406352 | Leave the same, no further action needed | March 20, 2024 | |||
 | Barry Franklin | 9/7/1952 | barryfranklinmedia@gmail.com | +16178350401 | Leave the same, no further action needed | March 20, 2024 | |||
 | Donald Henderson | 4/27/1967 | floridacatsfan@gmail.com | +15619069599 | Leave the same, no further action needed | March 22, 2024 | |||
 | Arif Beach | 7/16/1993 | arifbeach@gmail.com | +15616701400 | Leave the same, no further action needed | March 26, 2024 | |||
 | Rosemarie LaBruna | 7/11/1966 | roe7238@yahoo.com | +15618868780 | Leave the same, no further action needed | March 27, 2024 | |||
 | Carole Lesselbaum | 10/21/1959 | clesselbaum@optonline.net | +16317455155 | Leave the same, no further action needed | March 28, 2024 | |||
 | Natalie Whitco | 3/17/1973 | nataliewhitco.1@gmail.com | +15615453584 | Leave the same, no further action needed | March 29, 2024 | |||
 | Barry Rothman | 3/15/1955 | barothman@comcast.net | +15612133285 | Leave the same, no further action needed | April 1, 2024 | |||
 | Michael Petrizzo | 8/4/1966 | piasano8466@aol.com | +12013417239 | Leave the same, no further action needed | April 4, 2024 | |||
 | Michael Dombrowsky | 3/7/1955 | mikedombrowsky@bellsouth.net | +15616286642 | Leave the same, no further action needed | April 4, 2024 | |||
 | Dalton Vieitas | 7/5/1980 | daltonvieitas@gmail.com | +15616760055 | Leave the same, no further action needed | April 8, 2024 | |||
 | Geller Kiss | 4/2/1980 | gellerkiss@gmail.com | +19542250318 | Leave the same, no further action needed | April 9, 2024 |
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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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