RECERTIFICATION INTAKE

ATTENTION

OFFICE CLOSED JULY 14-18 FOR VACATION

If you have NEVER been certified for a card in Pennsyvania, please go back to drsam420.com and complete Step 1 - PATIENT INTAKE FORM

This form is for those who have already been certified in the state

IF YOUR LAST NAME HAS CHANGED - You will need to call the PA Dept of Health to have them update it in their system. Their Number 888-733-5595

Name*

First NameLast Name

Birth Date*

Date

Today's Date

Date

Phone Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState

Zip Code

HAVE YOU EVER HAD A PENNSYLVANIA MEDICAL MARIJUANA CARD?*

YES I HAVENO I HAVE NOT AND I REALIZE THIS IS THE WRONG FORM. I WILL RETURN TO DRSAM420.com under SET UP INITIAL CONSULTATION TO COMPLETE THE CORRECT FORM.

Emergency contact/POA

Occupation (retired, student etc are options)*

How did you hear about us/Dr Sam 420 ?

Condition(s) you were initially certified for*

Any medications you are currently taking ?*

How has medical cannabis/medical marijuana been working for you? *

LIST PREFERRED TIME FRAMES for us to call after 10am (MONDAY-FRIDAY). We will be calling from (724)257-2157.

PLEASE NOTE: WE CLOSE AT 430pm M-Th, and 2pm ON FRIDAY.

If you list just one time, we will call when we are available.

LIST PREFERRED TIME FRAMES AND DATES FOR US TO CALL. AFTER 10am. If you list only one exact time we will try to accommodate you within that hour. If Dr Sam is not available at a specific time and date he will call you when available.*

PREFERRED TIME, NOT AN OFFICIAL APPOINTMENT

We do NOT conduct calls BEFORE 10am OR AFTER 430pm M-Th, or after 2pm on Fridays. (WE ARE CLOSED SAT-SUN)

I am being evaluated for a physician's recommendation for Medical Cannabis. The physician will make recertification and recommendation based, in part, on the medical information I have provided. I hereby acknowledge that I have not misrepresented my medical condition to obtain this recommendation and it is my intent to use Medical Cannabis only as needed for the treatment of my medical condition, not for recreational or non- medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of Medical Cannabis. I have been informed of and understand the following. I consent to email, text and or voicemail from the office of My Way Medical, LLC (Dr Sam 420) while understanding that these are not HIPAA compliant forms of communication necessarily.

SEE PDF FORM - 3 pages - below and read them. At the bottom of this form you will sign to acknowledge that you understand these terms of consent.

I, the undersigned, acknowledge that I have read the Release of Liability and Acknowlegements, Agreements, Disclosures and Informed Consent and Payment policy. By signing below I agree to follow these policies.

By typing your full name here, you are giving your consent to the above forms. You understand that Dr Sam 420 does not compete employment paperwork or FMLA as we are not your primary care physician. Typing your name below serves as your legal signature. You also acknowledge as above if you only list one exact date/time to be called we may not be able to do so and will call during our availability.*

TYPE FULL NAME TO SERVE AS YOUR SIGNATURE

PAYMENT FOR THE MEDICAL CONSULTATION (SEPARATE FROM FEE TO STATE) DUE AT TIME OF CALL WITH DR SAM

I understand payment of $99 is due to Dr Sam420 at the time of the phone consultation, WHICH IS SEPARATE from the $50 fee due to the PA Dept of Health.*

YES I UNDERSTAND

By signing below, I understand that the payment, as stated above is due at the time of the phone consultation with Dr Sam. *

TYPE FULL NAME TO SERVE AS YOUR SIGNATURE

Date/Time

Now that you have completed the form, once you click below on "SUBMIT TO DR URICKS OFFICE", we will receive it.

FOR PHYSICIAN USE ONLY

plan: patient instructed to speak with pharmacist at dispensary to review any potential new medication interactions or if questions about particular strains sold at a particular dispensary.

Electronically Signed by Samuel Urick III, D.O.

* RECERTIFICATION *

For physician use only:

*********** RECERTIFICATION ***********

For physician use only:

* RECERTIFICATION *