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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 |
|---|---|---|---|---|---|---|---|---|---|
 | Nathaniel Burstin | 7/12/1983 | nateburstin@gmail.com | +19737256219 | Leave the same, no further action needed | February 7, 2024 | |||
 | Corey Frons | 7/17/1978 | frons@icloud.com | +19176761025 | Relieves pain reduces anxiety | No | Leave the same, no further action needed | October 2, 2024 | |
 | Peter Tartaglione | 12/11/1955 | pmt3122@gmail.com | +15943738760 | Helps me sleep calm down | No | Leave the same, no further action needed | April 2, 2025 | |
 | Courtney Kessler | 4/10/1980 | cdowning410@gmail.com | +17602713781 | Relaxes and eases pain to function | No | Leave the same, no further action needed | October 1, 2024 | |
 | Ileen Hattem | 6/8/1966 | ihattem@comcast.net | +15612891778 | Helps with pain and anxiety | No | Leave the same, no further action needed | November 1, 2024 | |
 | Stacey Lederberg | 1/3/1963 | staceylynn36@gmail.com | +19543365464 | Leave the same, no further action needed | October 22, 2023 | |||
 | Cailey Smith | 9/19/1995 | caileysm.19@gmail.com | +19143960407 | It has dramatically alleviated the pain and helps me sleep | No | Leave the same, no further action needed | September 28, 2024 | |
 | Kyle Schwartz | 11/18/1988 | kylegschwartz@gmail.com | +15165674762 | Request Doctor to contact me to make changes | January 17, 2024 | |||
 | Scott Lang | 8/22/1966 | scottlang@bellsouth.net | +19545574068 | Experiencing a calming and focusing Effects. Pressure from hernia operations and back pain. | None | Leave the same, no further action needed | September 20, 2024 | |
 | Caryn Stansell | 3/14/1969 | carynstansell@comcast.net | +13476754214 | Calms me | No | Leave the same, no further action needed | September 9, 2024 | |
 | Andrew Sankin | 10/23/1958 | a.sankin@hedgesource.org | +12025312345 | Helps with pain and nausea | No | Leave the same, no further action needed | March 17, 2025 | |
 | Samuel Palestine | 5/18/1951 | samrun@aol.com | +15088898244 | Relaxes me takes the edge off | No | Leave the same, no further action needed | September 16, 2024 | |
 | Cindy Roark | 4/26/1969 | cvr677@mail.harvard.edu | +18133738078 | Calms me down Helps with sleep | No | Leave the same, no further action needed | October 8, 2024 | |
 | Amanda Issacson | 3/2/2021 | amandajissacson@gmail.com | +15614515618 | Helps me sleep calms be down pain relief | No | Leave the same, no further action needed | March 12, 2025 | |
 | Mary Day | 4/2/1963 | mcday96@yahoo.com | +19782700527 | Calms me down | No | Leave the same, no further action needed | July 29, 2024 | |
 | Christa Tiessen | 3/8/1952 | ctiessen2022@yahoo.com | +19548065851 | Calms me down helps me sleep | No | Leave the same, no further action needed | September 9, 2024 | |
 | Joseph Mayhew | 11/16/1984 | jess.mayhew84@gmail.com | +13527139097 | Calms me down Lifts me up | No | Leave the same, no further action needed | August 2, 2024 | |
 | Kevin Salazar | 2/5/1958 | kevofla@yahoo.com | +19542143277 | Eases my pain | No | Leave the same, no further action needed | September 9, 2024 | |
 | Melinda Ruben | 10/22/1956 | melindaruben@gmail.com | +15613061690 | Leave the same, no further action needed | March 28, 2024 | |||
 | Elliot Klugman | 8/4/1950 | edk6771@gmail.com | +15163986560 | Leave the same, no further action needed | November 20, 2023 | |||
 | Gerald Martin | 12/26/1991 | gjmartin24@gmail.com | +17543672255 | It has helped me tremendously | No | Leave the same, no further action needed | August 30, 2024 | |
 | Terry Murray | 7/14/1950 | lukeness2@gmail.com | +19544613283 | Relaxes me reduces pain | No | Leave the same, no further action needed | February 26, 2025 | |
 | Marc Freeman | 5/12/1963 | marcbfreeman@gmail.com | +15164104542 | More relaxed. Sleep improvement | None | Leave the same, no further action needed | August 25, 2024 | |
 | Vicki Danelutti | 12/12/1960 | vickidanelutti@yahoo.com | +15613023285 | Less anxiety and able to fall asleep much better | No | Leave the same, no further action needed | February 23, 2025 | |
 | Vicki Danelutti | 12/12/1960 | vickidanelutti@yahoo.com | +15613023285 | Less anxiety and easier to fall asleep | No | Leave the same, no further action needed | February 23, 2025 |
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