Please Upload your Florida Marijuana Card

Patient Name

Gender

Email

Date of Birth

Phone

Address

Leave prescription as is or need to contact?

Please select which option(s) best describe why your seeking medical marijuana today.

Since your initial visit or last renewal, how has medical marijuana helped alleviate your symptoms? Did you observe functional or clinical improvement since starting the use of medical marijuana?

Have you experienced any negative side effects or adverse reactions while using medical marijuana?

Have you noticed improvement in symptoms and would like to continue the medical marijuana treatment?

Female patients only, are you pregnant or planning pregnancy?

General Diagnoses/Symptoms

Genito-Urinary Diagnoses/Symptoms

Muscle, Joint, and Bone Diagnoses/Symptoms

Gastrointestinal Diagnoses/Symptoms

Cardiovascular Diagnoses/Symptoms

ENT and Eyes Diagnoses/Symptoms

Pulmonary Diagnoses/Symptoms

Skin Diagnoses/Symptoms

Neurological Diagnoses/Symptoms

Psychiatric Diagnoses/Symptoms

Other Diagnoses/Symptoms (Had in the past)

Check illnesses, diagnose, and symptoms that have occurred in your Blood Relatives

I certify that the above information is correct to the best of my knowledge. I will not hold the doctor, office, or staff responsible for any errors or omissions that I may have made in the completion of this form. I also understand that my prescription may be adjusted to reflect any changes by the state on maximum dosages allowed. By checking this box, I acknowledge and agree that Oasis Marijuana Doctors and its doctors and staff have complied with Florida telehealth laws as defined in Florida Statute 456.47. I understand that telehealth includes the use of synchronous or asynchronous telecommunications technology for health care services. I acknowledge that telehealth providers may conduct patient evaluations and provide health care services without conducting a physical examination or researching a patient's medical history. I am aware that telehealth providers may only prescribe certain controlled substances in specific situations, as outlined in the statute. I understand that telehealth services may be provided when the telehealth provider and I are in separate locations. I also understand that telehealth services will be documented in my medical record in accordance with the same standards as in-person services. By checking this box, I confirm my understanding and agreement to these terms.

Patient/Carer/Guardian Signature