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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 |
|---|---|---|---|---|---|---|---|---|---|
 | Jaclyn Finkelstein | 4/29/1999 | jaclyn.finkelstein17@gmail.com | +15618868760 | Leave the same, no further action needed | March 15, 2024 | |||
 | Michelle Dowling | 3/6/1991 | mdowlingg6@gmail.com | +16508855525 | Leave the same, no further action needed | March 19, 2024 | |||
 | Ester Sherman | 1/27/1945 | esherman127@aol.com | +15615313102 | Leave the same, no further action needed | March 21, 2024 | |||
 | Kevin Mullaly | 8/13/1962 | kjmullaly@gmail.com | +19085108924 | Leave the same, no further action needed | March 25, 2024 | |||
 | Syed Shah | 11/26/1951 | shahsyed1214@gmail.com | +15612130496 | Leave the same, no further action needed | March 25, 2024 | |||
 | David Etzler | 2/10/2024 | davidetzler@yahoo.com | +15612123273 | Leave the same, no further action needed | March 25, 2024 | |||
 | Caryn Stansell | 3/14/1969 | carynstansell@comcast.net | +13476754214 | Leave the same, no further action needed | March 25, 2024 | |||
 | Maryanne Hurley | 1/30/1965 | mhurl65@aol.com | +19542533750 | Leave the same, no further action needed | March 25, 2024 | |||
 | Miguel Nievas | 4/20/1978 | miguelnievas@hotmail.com | +13479770457 | Leave the same, no further action needed | March 25, 2024 | |||
 | Michael Kaplan | 4/1/1962 | kaplan.mike@gmail.com | +15187634000 | Leave the same, no further action needed | March 25, 2024 | |||
 | TATIANE LEVY | 5/11/1980 | tatianelevy@gmail.com | +19545575568 | Leave the same, no further action needed | March 25, 2024 | |||
 | Joel Hartstone | 12/10/1945 | jstonegate@att.net | +18609304975 | Leave the same, no further action needed | March 26, 2024 | |||
 | Robin Baritz | 11/21/1955 | rbaritz1@gmail.com | +15618667233 | Leave the same, no further action needed | March 26, 2024 | |||
 | Ilene Laplace | 7/16/1948 | ilenelaplace@gmail.com | +15615049493 | Leave the same, no further action needed | March 27, 2024 | |||
 | Scott Glover | 8/16/1962 | scottspaintshop@gmail.com | +17194291046 | Leave the same, no further action needed | March 27, 2024 | |||
 | Ricardo Arevalo | 9/19/1955 | twinterm@aol.com | +13055628248 | Leave the same, no further action needed | March 28, 2024 | |||
 | Norman Schulman | 6/17/1959 | nschulma@aol.com | +15612399771 | Leave the same, no further action needed | March 28, 2024 | |||
 | Michael Berez | 1/30/1979 | michaelberez@gmail.com | +19172392916 | Leave the same, no further action needed | March 28, 2024 | |||
 | Ileen Hattem | 6/8/1966 | ihattem@comcast.net | +15612891778 | Leave the same, no further action needed | March 29, 2024 | |||
 | Mary Rulau | 11/26/1970 | onemathwizard@gmail.com | +17726789624 | Request Doctor to contact me to make changes | March 29, 2024 | |||
 | April Cole | 4/24/1968 | aprilbcole@yahoo.com | +17038504959 | Leave the same, no further action needed | March 30, 2024 | |||
 | Gerald Martin | 12/26/1991 | gjmartin24@gmail.com | +17543672255 | Leave the same, no further action needed | March 30, 2024 | |||
 | Angela Vargas | 10/5/1991 | angelamariavar@hotmail.com | +15612132056 | Leave the same, no further action needed | March 31, 2024 | |||
 | Laurie Harper | 10/8/1953 | lauriealex1@gmail.com | +19175617958 | Leave the same, no further action needed | April 1, 2024 | |||
 | Venetia Tully | 9/25/1969 | veech47@gmail.com | +15614798171 | Leave the same, no further action needed | April 2, 2024 |
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