RECERTIFICATION INTAKE

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

Dr Sam 420
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*

MonthDayYear
Date
Today's Date

MonthDayYear
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 daily prescription medications you are currently taking ? If yes, please list*
How has medical cannabis/medical marijuana been working for you? *
What time(s) of day do you use/medicate with medical cannabis/medical marijuana?

all day, any timejust at bedtimejust in the morningevenings and onwardOther
Which methods on consumption work best for you? Select all that apply.*

Vaporizing (Cartridges, Concentrates)FlowerTroches (gummy form, hard candy form)Tincture (liquid drops)CapsulesRSOTopical ointment/cream/salve
Have any of the methods above resulted in any cough, sore throat, headache, chest congestion, chest pain, nausea, vomiting or any other side effects like making you feel anxious or paranoid? If YES, please describe.*
LIST PREFERRED TIME FRAMES for us to call after 10am (MONDAY-FRIDAY). We will be calling from (724)257-2157.
LIST PREFERRED TIME FRAMES AND DATES FOR US TO CALL. WE ARE CLOSED ON WEEKEND. WE OPEN AFTER 10am. If you list only one exact time we will try to accommodate you within that hour. If Dr Sam Urick is not available at a specific time and date he will call you when available.*
PREFERRED TIME, NOT AN OFFICIAL APPOINTMENT
HOURS: Monday-Thursday 10am-430pm, Friday 10am-2pm

CLOSED ON WEEKENDS.
Consent for treatment and medical cannabis use
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. You also consent to receiving email/text/phone call follow ups in subsequently to send reminders about renewing your medical card until which time you can indicate you no longer wish to receive email/text/phone calls.
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. You understand that we will contact you by telephone, email or text messaging even though they are not HIPAA secure methods of communication and you can request if you would not prefer a certain type of communication with us. 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 URICK
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. I authorize Dr Sam to bill my credit card/debit card billed at the time of the consultation.*
TYPE FULL NAME TO SERVE AS YOUR SIGNATURE
Date/Time
Address*

Street Address

Street Address Line 2

CityState

Zip Code
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:
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.
Should be Empty:

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

Consent for treatment and medical cannabis use

For physician use only:

* RECERTIFICATION *