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Patients Seen M-Th: 8:30am-11:15 12:45-3:30pm Sat: 8:30AM-11:15am
(Closed Fridays and open only 1st & 2nd Saturday of the month)
CALL/TEXT 904-586-0041
Email Us
2624 Atlantic Blvd Suite #5
Jacksonville, FL 32207
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Type of Appointment
(Required)
New Patient
Followup Patient
Transfer Patient
Patient ID (On Your Medical Marijuana Card)
(Required)
Patient First Name
(Required)
Patient Last Name
(Required)
Date of Birth
(Required)
Month
Day
Year
Gender on Driver's License
(Required)
Male
Female
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Maine
Maryland
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New York
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Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Please list your current medications:
Are you pregnant or breast-feeding?
(Required)
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 conditions that apply to you
Select at least 3 qualifying conditions
(Required)
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
Other conditions:
Are you allergic to any medications?
(Required)
Yes
No
Please list the medications you are allergic to
(Required)
Have you been hospitalized?
(Required)
Yes
No
Please list and describe your hospitalizations with dates.
(Required)
Have you had surgery?
(Required)
Yes
No
Surgical History: (Please include year, reason, and date.)
(Required)
Family History – Father
(Required)
Alive
Deceased
Unknown
Family History – Mother
(Required)
Alive
Deceased
Unknown
Are you using illicit drugs?
(Required)
Yes
No
Do you drink alcohol?
(Required)
Yes
No
Do you smoke cigarettes?
(Required)
Yes
No
Are you pregnant/breastfeeding or planning pregnancy within the next year?
(Required)
Yes
No
Do you have any family history of addiction?
(Required)
Yes
No
Please choose your recommendation package
(Required)
Packages described below.
All Routes
All Except Sublingual
All Except Inhalation
Topical, Sublingual, and Inhalation
Edibles and Inhalation
Edibles, Inhalation, and Oral
All Inhalation
Balancing Act
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
Balancing Act
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
Everything but the Inhalation
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
Topicals, Tinctures, and Vapes
Inhalation 300 day / 21000 70 days Edibles 25 day / 1750 70 days Oral 25 day / 1750 70 days Sublingual 0 Topical 0 Total 350 day / 24500 70 days
Edibles and Vapes
Inhalation 300 day / 21000 70 days Edibles 50 day / 3500 70 days Oral 0 Sublingual 0 Topical 0 Total 350 day / 24500 70 days
Edibles, Vapes, and Caps
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
The Inhalator
Inhalation 350 day / 24500 70 days Edibles 0 Oral 0 Sublingual 0 Topical 0 Total 350 day / 24500 70 days
If you have a Florida ID, but the address is not current.
(Required)
You must update your Florida Driver’s license to the current information before your appointment. The Florida Medical Marijuana Use Registry (MMUR) is connected to Florida’s Department of Highway Safety and Motor Vehicles and will pull your info from their database. If it is not correct you will not receive your medical marijuana hard copy license. You cannot make these changes after we have submitted your application to the state. Therefore, you cannot be seen unless your license is up to date.
I understand
If you do not have a Florida ID or Driver's License.
(Required)
The Florida MMUR connects to the OMV to access patients’ State ID photo and to verify their address. If a patient does not have a Florida license, they must provide the following directly through the registry. ⢠A Photo – The photo must be passport style and can be purchased at UPS, Walgreens, CVS and other professional photo studios. Please ask for a digital picture so that you may upload it to the MMUR. Do not upload a photo of a picture. ⢠Proof of Residence – You must provide at least TWO of the following: o Deed/Mortgage/Lease Agreement. o Work order or utility hookup dating back 60 days from application. o 60-days old utility bill. Phone or cable bill will not suffice. o 60-days old mail from a financial institution. o 60-days old mail from federal, state, county, or municipal government. o A statement or letter from someone who resides with patient with one proof that this person is a resident.
I understand
Disclaimer about exemptions
(Required)
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
Untitled
(Required)
I understand how exemptions work
Are you running out of any of your routes?
(Required)
No
Yes
Please be aware you will need to do an exemption request and renew it to keep the higher limit.
Signature
Once you hit submit you will be taken to the medical marijuana consent form, please complete it and then you are all done.
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Medical Marijuana Exemption Request
"
*
" indicates required fields
Company
This field is for validation purposes and should be left unchanged.
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?
*
No
Yes
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.
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