• *********** RECERTIFICATION ***********

    Dr Sam 420
  • 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

     

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  • 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.

  • 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.

     

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

     

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

     

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  • 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.

  • Should be Empty: