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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 904-586-0041
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2624 Atlantic Blvd Suite #5
Jacksonville, FL 32207
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" indicates required fields
Patient First Name
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Patient Last Name
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Preferred Name
Date of Birth
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Month
Day
Year
Gender on Driver's License
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Male
Female
Street Address
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City
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Zip Code
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Phone
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Email
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Please List Your Medical Conditions
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Please select a recommendation package
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All Routes
All Except Sublingual
All Except Inhalation
The Inhalator Supreme (Distillates & RSO)
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
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MM slash DD slash YYYY
Disclaimer #1
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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 #2
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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
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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 have read and understand.
Disclaimer about exemptions
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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
I understand exemptions
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I understand how exemptions work.
Are you running out of any of your routes?
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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
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" indicates required fields
Patient Full Name
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First
Last
Patient Date of Birth
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MM slash DD slash YYYY
Your birthday
Patient Phone #
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What types of products/routes are you using?
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Inhalation
Edibles
Oral
Sublingual
Topical
Smokable
What routes are you requesting the exemption form for?
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Smoking
Oral
Edibles
Topical
Sublingual
Inhalation
How often do you use your products?
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Once daily
Twice daily
Every few hours
Other
How much product do you use at a time?
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Please explain your current regimen below?
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What about this route or product is better for you?
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Why do you choose it over other products?
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How do you feel this increase will better your treatment options?
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Name
First
Last
Have you had an exemption before?
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No
Yes
A disclaimer..
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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.
Name
This field is for validation purposes and should be left unchanged.
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