First Visit Form
This initial visit patient form is used by medical practitioners to collect information from patients as they arrive at the office for an initial visit.
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18800 Delaware St., STE 110, Huntington Beach, CA 92648

714-596-0808

Patient Name:

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Phone

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Email *

Date of Birth

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MM
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DD
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YYYY
Address

Height (in feet)

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Weight (in pounds)

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Reason for visit/ Symptoms

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Have you ever tried any cannabis product (CBD or smoked cannabis (weed))?
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Pharmacist Recommendation (please leave blank)

I understand that:

Once “this facility” discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. 
The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information.
I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524).My records are protected and cannot be disclosed without written permission 
This Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PLEASE WRITE YOUR NAME

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Disclaimer
These statements have not been evaluated by the Food and Drug Administration.  This product is not intended to diagnose, treat, cure or prevent any disease
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