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Patients Seen M-Th: 8am-3:30pm Fri: 8am-11:30am Sat: 8AM-11:30am(Closed first Friday and open first Saturday of the month only)CALL/TEXT 904-586-0041Email Us2624 Atlantic Blvd Suite #5Jacksonville, FL 32207

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Affordable Marijuana License

PATIENT DEMOGRAPHICS

Telemedicine appointments are only available to followup patients.

"*" indicates required fields

Patient First Name*

Patient Last Name*

Preferred Name

Date of Birth*

Month

Day

Year

Gender on Driver's License*

Male

Female

Street Address*

City*

Zip Code*

Phone*

Email*

Please list your current medications*

Are you pregnant or breast-feeding?*

Yes

No

We cannot see patients that are pregnant or beast-feeding. If you have questions please call our office at 904-586-0041. Thank you for understanding.

Please select at least 3 qualifying medical conditions you have*

ADHD

AIDS

ALS

Alopecia Areata

Alzheimer’s

Ankylosing Spondylitis

Anorexia

Anxiety

Arthritis

Asthma

Autism

Autoimmune Hemolytic Anemia

Balance Disorder

Bipolar Disorder

Bone Pain

Brain Trauma

Camptocormia

Cancer

Chronic Abdominal

Chronic Fatigue Syndrome

Chronic Nausea

Chronic Pain

Chronic Vomiting

Crohn’s

Degenerative Disc Disease

Depression

Diabetes

Diabetic Pain Neuropathy

Diabetic Retinopathy

Diverticulitis

Dysphagia

Dystonia

Ehler-Danios Syndrome

Epilepsy

Fibromyalgia

Glaucoma

Gout

Grave’s Disease

Gullain-Barre Syndrome

HIV

Hashimoto’s Thyroiditis

Headaches (Chronic)

Hemiplegia

Huntington’s Disease

Hydrocephalus

Idiopathic Thrombocytopenic Purpura

Inflammatory Bowel Disease

Insomnia

Irritable Bowel Syndrome

Juvenile Rheumatoid Arthritis

Low Back Pain

Lupus

Meralgia Paresthesia

Migraines

Multiple Sclerosis

Muscle Spasms

Muscular Dystrophy

Musculoskeletal Pain

Myasthenia Gravis

Neuromyelitis Optica

Neuropathic Pain

OCD

Obstructive Pulmonary Disease

Osteoarthritis

Osteoporosis

PANS/PANDAS

PTSD

Pancreatitis

Panic Attacks

Parkinson’s

Pelvic Pain

Peripheral Artery Disease

Polyarteritis Nodosa

Post-Polio Syndrome

Psoriasis

Psoriasis

Rheumatoid Arthritis

Scoliosis

Sjogren’s Syndrome

Social Anxiety

Spinal Stenosis

Tardive Dyskinesia

Terminal Conditions

Tics

Tietze Syndrome

Tourette’s Dermatologic Conditions

Ulcerative Colitis

Vitiligo

Do you have any other medical conditions?*

Are you allergic to any medications?*

Yes

No

Please list the medications you are allergic to*

Have you been hospitalized?*

Yes

No

Please provide details of your hospitalization(s) with dates.*

Have you had any surgeries?*

Yes

No

Please list your surgeries with dates they were performed.*

Family History – Father

Alive

Deceased

Unknown

Father Cause of Death*

Cancer

Hypertension

Diabetes

Natural Causes

Family History – Mother

Alive

Deceased

Unknown

Mother Cause of Death*

Cancer

Hypertension

Diabetes

Natural Causes

Are you using illicit drugs?*

Yes

No

Do you smoke cigarettes?*

Yes

No

Do you drink alcohol?*

Yes

No

Are you pregnant/breastfeeding or planning pregnancy within the next year?*

Yes

No

Do you have any family history of addiction?*

Yes

No

Please select a recommendation package*

All Routes

All Except Sublingual

All Except Inhalation

The Inhalator Supreme

Edibles and Inhalation

Edibles, Inhalation, and Oral

All Inhalation

Inhalation 200 day/ 14000 70 days Edibles 50 day / 3500 70 days Oral 50 day / 3500 70 days Sublingual 25 day / 1750 70 days Topical 25 day / 1750 70 days Total 350 day / 24500 70 days

Inhalation 200 day/ 14000 70 days Edibles 50 day / 3500 70 days Oral 50 day / 3500 70 days Sublingual 0 day / 0 70 days Topical 50 day / 3500 70 days Total 350 day / 24500 70 days

Inhalation 0 Edibles 50 day / 3500 70 days Oral 150 day / 7000 70 days Sublingual 150 day / 7000 70 days Topical 50 day / 3500 70 days Total 350 day / 24500 70 days

Inhalation 200 day / 14,000 70-day Edibles not applicable Oral 150 day / 10,500 mg 70-day Sublingual not applicable Topical not applicable Total 350 day / 24,500 70-day Smoking 2.5 oz every 35 days

Inhalation 300 day / 21000 70 days Edibles 50 day / 3500 70 days Oral 0 Sublingual 0 Topical 0 Total 350 day / 24500 70 days

Inhalation 200 day / 14000 70 days Edibles 50 day / 3500 70 days Oral 100 day / 7000 70 days Sublingual 0 Topical 0 Total 350 day / 24500 70 days

Inhalation 350 day / 24500 70 days Edibles 0 Oral 0 Sublingual 0 Topical 0 Total 350 day / 24500 70 days

Please pick a date you would like for your appointment*

MM slash DD slash YYYY

Disclaimer #1*

Hi, this is a quick note from Dr Pulido: Due to a high volume of telemedicine requests, we are unable to offer exact times for telemedicine appointments. For morning appointments, they run from 8am-11:30am & for afternoon appointments from 1pm-4pm. Your call may happen anytime during the window. Please do not call about your appointment unless it is after 11:30 for morning appointments or 4pm for afternoon appointments. We appreciate your understanding.

I understand

Disclaimer #1*

Hi, this is a quick note from Dr. Pulido: Due to a high volume of telemedicine requests, we are unable to provide exact appointment times. For Friday appointments only, your phone call may happen anytime between 8:30am and 12:00pm. Please do not call about your appointment unless it is after 12:00pm and you have not yet received a call. We appreciate your understanding.

I understand

Disclaimer #2*

Telemedicine appointments are first come, first served & we max out at 100 per day. If you don’t complete all the steps (1. this form, 2. the consent form, and then 3. payment) you will be placed on a waiting list and may not get the appointment on the day you desire. After you submit this form you will be redirected to the consent form and then payment so don’t close out of your internet browser until you are sure all the steps have been completed.

I understand

Disclaimer #3*

Due to recent changes with the Florida MMU, it is now ONLY possible to move mgs (types of product available for purchase) within the first 70-day cycle of a patients 7-month orders. Changes after that 70 day cycle will require an exemption request, which is up to the State to approve or deny based on the patient’s history.

I understand

Disclaimer about exemptions*

Have you previously had an exemption? Please understand that per State requirements, exemptions expire and must be renewed in a separate process from your regular renewal appointments if you wish to keep them.

I have NOT previously had an exemption

I have previously had an exemption

More Information Here FL State Exception Explanation & Application Form

i understand exemptions*

I understand how exemptions work

Are you running out of any of your routes?*

No

Yes

Please be aware you will need to do an exemption request and renew it to keep the higher limit.

After you press ‘Submit’ you will be redirected to our document signing service to complete the medical marijuana consent form. Please initial all boxes, then sign and date at the bottom. Then you will be redirected to our payment platform to pay for your appointment. After that you are all done and we will contact you to confirm your appointment.

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Medical Marijuana Exemption Request

"*" indicates required fields

Patient Full Name*

First Last

Patient Date of Birth*

MM slash DD slash YYYY

Your birthday

Patient Phone #*

What types of products/routes are you using?*

Inhalation

Edibles

Oral

Sublingual

Topical

Smokable

What routes are you requesting the exemption form for?*

Smoking

Oral

Edibles

Topical

Sublingual

Inhalation

How often do you use your products?*

Once daily

Twice daily

Every few hours

Other

How much product do you use at a time?*

Please explain your current regimen below?*

What about this route or product is better for you?*

Why do you choose it over other products?*

How do you feel this increase will better your treatment options?*

Name

First Last

Have you had an exemption before?*

A disclaimer..*

An exception is created on open orders, once the orders expire the exception will as well. To renew the exception you will need to fill out this form, have new active orders, and do a visit each time.

I understand.

URL

This field is for validation purposes and should be left unchanged.

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