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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 |
|---|---|---|---|---|---|---|---|---|---|
 | David Etzler | 2/10/2024 | davidetzler@yahoo.com | +15612123273 | Relaxes me Calms me Reduces pain from migraines | No | Leave the same, no further action needed | October 15, 2024 | |
 | William Leswing | 2/21/1975 | williamleswing@yahoo.com | +15618664671 | Leave the same, no further action needed | May 14, 2024 | |||
 | Amy Fisher | 5/17/1988 | a.l.macmurray@gmail.com | +15166412998 | Calms me down helps me sleep | No | Leave the same, no further action needed | November 15, 2024 | |
 | Charles [MARGOSSIAN | 9/22/1951 | cmargossian@comcast.net | +17812541789 | Calms me | None | Leave the same, no further action needed | January 12, 2026 | |
 | Warren Seeley | 11/13/1954 | kote599@yahoo.com | +19084327705 | Relaxes me helps me sleep | No | Leave the same, no further action needed | January 8, 2025 | |
 | Tatiane Levy | 5/11/1980 | tatianelevy@gmail.com | +19545575568 | Pain relief | No | Leave the same, no further action needed | November 22, 2024 | |
 | Linda Hiward | 3/7/1947 | drlbh47@aol.com | +15619017260 | Helps with pain and anxiety | No | Leave the same, no further action needed | January 6, 2026 | |
 | Michael Prairie | 9/8/1980 | mprairie5@gmail.com | +14078979007 | Yes | No | Leave the same, no further action needed | June 7, 2025 | |
 | Arlene MacMurray | 1/23/1951 | bookwormny@aol.com | +15164455739 | I sleep better at night. Feel better during the day when I get anxious. | No | Leave the same, no further action needed | January 1, 2026 | |
 | Stephanie Rizzo | 1/9/1970 | srizzo70@gmail.com | +14077344535 | Anxiety reducing and sleep | No | Leave the same, no further action needed | December 31, 2025 | |
 | Mary Rulau | 11/26/1970 | onemathwizard@gmail.com | +17726789624 | everything is the same as my last visit. I function better with this medication. | none. | Leave the same, no further action needed | October 3, 2024 | |
 | Edmund Conroy | 6/11/1949 | steveconroy.yachts@yahoo.com | +18433275222 | Pain and anxiety | No | Leave the same, no further action needed | October 28, 2024 | |
 | Richard Leipzig | 12/16/1957 | rleipzig@aol.com | +19176895858 | Leave the same, no further action needed | May 8, 2024 | |||
 | Robin Deluca | 4/21/1957 | robindelu@gmail.com | +17727137573 | Leave the same, no further action needed | July 2, 2024 | |||
 | Joseph Qyick | 3/10/1976 | josephquick@bellsouth.net | +13054793919 | Relaxes me | No | Leave the same, no further action needed | December 18, 2025 | |
 | Sammy Kaufman | 12/18/1987 | kaufman.sammy@gmail.com | +13476458364 | Helps with nausea pain insomnia | No | Leave the same, no further action needed | December 18, 2025 | |
 | Jack Serendensky | 8/7/1957 | pat_jake1964@yahoo.com | +19542457688 | Calms me down Helps with pain | No | Leave the same, no further action needed | November 6, 2024 | |
 | April Cole | 4/24/1968 | aprilbcole@yahoo.com | +17038504959 | Calms me Allows me to sleep | None | Leave the same, no further action needed | October 1, 2024 | |
 | Steve Thorp | 9/27/1955 | stevet33@bellsouth.net | +15612516032 | Helps with pain and nausea | None | Leave the same, no further action needed | October 15, 2024 | |
 | Louis Irizarry | 4/23/1966 | louis.irizarry@icloud.com | +13057988555 | Relieves anxiety helps me sleep through the night | No | Leave the same, no further action needed | November 25, 2024 | |
 | Gary Phillips | 7/14/1969 | garysphillips@gmail.com | +13233951178 | Leave the same, no further action needed | February 22, 2024 | |||
 | Norman Schulman | 6/17/1959 | nschulma@aol.com | +15612399771 | Reduces pain and anxiety | No | Leave the same, no further action needed | October 21, 2024 | |
 | Maryanne Hurley | 1/30/1965 | mhurl65@aol.com | +19542533750 | Yes | None | Leave the same, no further action needed | September 4, 2024 | |
 | Mary Rubenzahl | 9/22/1948 | anernmarye@gmail.com | +15616374746 | Leave the same, no further action needed | March 29, 2024 | |||
 | Jill Morris | 9/15/1965 | jmorrisphd@yahoo.com | +15617020592 | Helps with pain and anxiety | None | Leave the same, no further action needed | November 15, 2024 |
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