In-Office, New Med Card Registration Form

Completion time: 10-14 minutes

This form is for:

Patients new to our practice
First-time application for an FL card

Protected Health Information (PHI)

KindHealth medical service collects a fair amount of your personal information. We upload the required identifying data to the Florida state OMMU registry to get your marijuana card. This info is considered PHI; although we store it on our local computer, we use it solely for this business transaction. We do not share, sell, or give access to any third party, nor do we send it to or store it in the 'cloud'. I've included our privacy notice below.

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- Step 1 of 9

Ever apply for a Florida med card before? *

STOP HERE. This online application is only for those who have never previously applied for a Florida marijuana card. If you have applied for a med card in the past, go to Renew Your Medical Card Online in Florida. If you are a KindHealth patient already, re-apply at Marijuana Card Renewal Online. Call (786) 953-6838 for more information.

Today's Date *

SSN *

*Required for the Medical Marijuana Use Registry

FL Driver's license # or State ID # *

*Required for the Medical Marijuana Use Registry

DATE OF BIRTH *

First Name *

Last Name *

PHONE *

Email *

Confirm Email

FLORIDA ADDRESS (same as driver's license) *

Address Line 1

Address Line 2

City

State

Zip Code

If your FL address does not match the address on your driver's license, please stop and speak with the KindHealth staff.

FL County *

WEIGHT (lb) *

Age *

Sex Assigned at Birth *

Male
Female

PREGNANT or PLANNING to be? *

Are you currently breast feeding? *

Was last cycle over 28 days ago? *

Why was your cycle late? *

Menopause
Perimenopause
Hysterectomy
I may be pregnant
Other

Please explain *

GENERAL MEDICAL HISTORY (check all that apply)

sweats
weight change
sleep problems
fatigue
migraine
headaches

Respiratory

asthma
cough
bronchitis
COPD
COVID-19
lung disease
wheeze
sputum
short of breath

Heart Disease

Stroke
blood clots
irreg heart beat
Angina
heart attack
heart disease
dizziness
chest pain
CAD

Gastrointestinal

nausea/vomiting
abdominal pain
swallowing problems
liver diseases
heartburn
changed bowel habits

Bones /Joints

back/neck pain
stiffness
swelling
gout
arthritis
pain

Psychological

Anxiety
mood swings
Schizophrenia
Depression
ADHD/ADD
Bipolar
PTSD
hallucinations
delusions

Endocrine

Diabetes
Hyperthyroid
Hypothyroid
Pancreas
Adrenal glands

Florida CONDITIONS (check any that apply)

Hepatitis C
Cancer
Multiple sclerosis
Crohn's disease
Epilepsy
HIV/AIDS
Parkinson disease
Glaucoma
ALS (Lou Gehrig's)
Muscular dystrophy
Terminal illness
Post-traumatic stress (PTSD)

Don't see your problem yet? Check here.

Have you used any other medical treatments?

What types of treatments have you taken for your medical condition in the past?

HAVE YOU USED MARIJUANA? *

How did you use it? *

Flower
Vape
Oil
Edibles
Topicals
Concentrates

What type? *

Sativa
Indica
Hybrid
More than one type
I don't know

How often? *

less than once/day
1-3 times/day
4-5 times/day
more than 5 times/day

How well did it work? *

Extremely well
Very well
Moderately well
Slightly well
Not at all

Do you get any MMJ SIDE EFFECTS? *

List cannabis side effects *

DO YOU TAKE ANY MEDICATIONS? *

List them. If your list is long, just let the staff know. *

Do you have any drug ALLERGIES? *

List of drug allergies *

Any alcohol/drug/SUBSTANCE ABUSE? *

If yes, please explain *

Do you take any of these BLOOD Thinners? (Check all that apply)

Aspirin
Coumadin
Plavix
Persantine
Xarelto

How did you hear about us? *

internet
drive-by
flyer
friend
dispensary
local business
radio/news
other

GDPR Agreement *

KindHealth may store my information for this inquiry.

ATTESTATION

Patient ATTESTATION- 1 minute read

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PATIENT ATTESTATION.

I attest that I am a Florida resident and the information on this form is correct. Any and all medical history, presented or omitted, is factual and complete to the best of my knowledge. I do not plan or intend to use my physician’s recommendation for purposes of illegally obtaining, growing, or distributing medical marijuana. I am aware that the KindHealth doctor will revoke my recommendation and legal actions will be taken if it is found at any time that I have perjured or misrepresented myself or my condition, intentions, or falsiﬁed any medical records to the physician. I have read and understood this attestation. DO NOT SUBMIT THIS FORM IF YOU DO NOT UNDERSTAND AND AGREE WITH THIS ATTESTATION.

Patient Attestation Reviewed *

I have read, understood and agree with the patient attestation.

LIABILITY

RELEASE of LIABILITY - 5 minute read

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RELEASE of LIABILITY

I attest that I am a Florida resident and the information on this form is correct and any medical history presented or discussed with the doctor is all factual and complete to the best of my knowledge. I do not plan or intend to use my physician’s recommendation for purposes of illegally obtaining, growing, or distributing medical marijuana. I am aware that the KindHealth doctor will revoke my recommendation and legal actions will be taken if it is found at any time that I have perjured or misrepresented myself or my condition, intentions, or falsified any medical records to the physician. Solely for verification purposes, I authorize the KindHealth staff/contracted doctors to converse regarding my medical condition.

I understand the United States Food and Drug Administration does not regulate cannabis and it may therefore contain unknown quantities of active ingredients, impurities and/or contaminants. I understand the potential risks associated with an elevated daily consumption of medical marijuana including risks with respect to the effect on my cardiovascular, pulmonary systems and psychomotor performance. There are also risks associated with the long-term use of marijuana as well as potential drug dependency. I am aware the benefits and risks of using marijuana are not fully understood and may involve risks not yet identified. In requesting an approval or recommendation for the use of medical marijuana, I assume full responsibility for any risk involved in this action.

I understand medical marijuana smoke contains chemicals known as tars that may be harmful to my health. Research indicates that vaporizing cannabis may eliminate exposure to tar. If I experience any respiratory problems or other ill effects be experienced in association with its use, I should discontinued its use and report to the physician immediately.

I am advised the use of medical marijuana might affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my cannabis use.

Florida’s Medical Marijuana Legalization Initiative - Amendment 2, approved November 08, 2016 provides for the possession of medical marijuana for the personal medical purposes of the patient with a physician approval or recommendation. KindHealth staff, physicians and/or representatives are not providing medical marijuana, nor are they encouraging any illegal activity in my obtaining medical marijuana.

I attest that I am not a member, employee or agent of any media or law enforcement agency. It is illegal to ﬁlm or record in this ofﬁce with a video camera, cell phone or any other recording devise be it a still image, video or audio. This is a direct violation of HIPAA regulations and patient/doctor conﬁdentiality.

I, the undersigned, I affirm that I have a serious medical condition that negatively affects my quality of life. I found, or am interested in ﬁnding, whether or not medical marijuana provides substantial relief and improvement in my condition. I hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal marijuana treatment. The physician, staff, and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider.

I realize I am paying KindHealth for an evaluation to assess my eligibility for the OMMU Registry. This evaluation may find my condition as not appropriate for Florida state certification. In the case you are not found eligible, there is no refund to you as our staff has performed its medical service appropriately. In short, I am paying KindHealth for the service, not a guaranteed eligibility.

Should an approval be made for my medicinal use of marijuana, I understand there is a renewal date specified by the physician depending on the condition. I understand that it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval.

Flower
Given the potential adverse effects of smoking marijuana flower, the FL Board of Medicine requires doctors have patients use a vapor method of inhalation before advancing to flower. Purchase of a vape pen from the MMTC serves as ‘proof of vaping.’ If you then have vape pen related side effects, such as a cough, sore or harsh throat, only then can the ordering doctor add flower to your prescription. This purchase helps fulfill the requirement for both the state and doctor.

I have been given a copy of the KindHealth Notice of Privacy Practices for my review. By signing this form, I am consenting to KindHealth’s use and disclosure of my PHI in accordance with those terms. Furthermore, the undersigned, or anyone acting on my behalf, agree to hold the physician and his/her principals, agents, and employees, free of and harmless from any liability resulting from the use of medical marijuana.

Release of Liability Reviewed *

I have read, understood and agree with the Release of Liability.

PRIVACY

Notice of Privacy Practices - 4 minute read

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NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

KindHealth Assurance
KindHealth is committed to ensuring your health information is secure, and we protect your anonymity and privacy. We put physical, electronic and managerial procedures in place to safeguard and secure any data you provide us.

What is Protected Health Information?
Health information is any information about you, in any form that we either create, or receive from outside sources. This Notice of Privacy Practices refers to all health information as protected health information or “PHI”. Individually identifiable PHI includes health and demographic information collected from you which can reasonably be used to identify you.

PHI and the Law
Both state and federal law require KindHealth to limit the manner it uses or discloses information about a patient or a patient’s PHI in order to maintain your privacy. In addition, we are required to provide you with this privacy notice setting forth our legal duties and obligations, and your rights with respect to your PHI. All KindHealth care professionals and staff providing services in our practice are subject to this Notice of Privacy Practices and we may update the Notice from time to time, in which case we will prominently display the updated version.

Uses and Disclosures of Your PHI
This list is not all-inclusive. KindHealth uses any information you provide to us only in accordance with this Notice of Privacy Practices. KindHealth uses any information you provide to us only in accordance with this privacy statement. If you are an existing patient, you have already signed a consent. We will ask you to sign a consent if you are a new patient. The consent will allow KindHealth to use and disclose your PHI for your treatment, to obtain payment for the services we render to you and to assist us in our healthcare operations. We may use or disclose your PHI for your treatment or payments.

Treatments:
KindHealth may disclose and verify me as a patient to any law enforcement agency, my physician(s), or Child Protective Services.
Validate my status as a patient using the online patient veriﬁcation system.
Our medical records personnel may review your chart to ensure proper placement of all lab and other tests results in your chart prior to your visit.
Our medical staff or physicians may communicate with laboratory or other testing facilities to review test results prior to your visit.
KindHealth staff and doctors may discuss your case among themselves or review your medical treatment with referring physicians or physicians to whom they have referred you for care.
Personnel in this office may discuss your medical information with a hospital or other healthcare facility treating you or we may discuss this information with another healthcare provider who is treating you at such a facility.
This practice may announce the names of patients in the waiting area, and others may hear your name.
Our practice may leave VMs on your home answering machine; or send postcard, email or text appointment reminders.
This practice may disclose health information to a pharmacy when we order a prescription for you.
This practice may send you information about other health-related benefits and services that may be of interest to you.
Payment Delinquency:
This practice may provide consumer-reporting agencies with credit information regarding your payment history.
This practice may provide information to collection agencies, our attorneys, or in a legal action for purposes of obtaining payment of delinquent accounts.

A printed copy of this form is available on request. I understand that KindHealth reserves the right to make changes to the terms of its Notice of Privacy Practices. I have read and understand the above Notice of Privacy Practices.

Privacy Practices Reviewed *

I have read, understood and agree with the Privacy Practices.

Sign up for 7-month visit reminders by text message (HIGHLY RECOMMENDED)

CONSENTto receive text message reminders *

YES. TEXT my 7-month visit reminders. Cancel at any time.
No. I do not wish to receive text message reminders.

SMS Terms of Service / Privacy Policy

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SMS TERMS of SERVICE

KindHealth uses SMS/text messaging to send patients upcoming visit reminders. By opting-in to our SMS subscription tool, you agree to receive recurring text reminders for your scheduled visits. You may opt-out at any time by replying "UNSUBSCRIBE" to the text field.

While we do not charge for this service, you may be responsible for charges and fees associated with text messaging imposed by your wireless provider. To the extent permitted by applicable law, you agree that we will not be liable for failed, delayed, or misdirected delivery of any information sent through the service, any errors in such information, and/or any action you may or may not take in reliance on the information or Service. If help is needed, type "HELP" into the text field, or call us at (786) 953-6838 and one of our team members will assist you as soon as possible.

SMS PRIVACY POLICY

Your right to privacy is important to us. Your SMS number remains protected health information and we do not share it with any third party entities. We use this information solely to send you text notifications for your scheduled upcoming doctor visit, or to relay follow-up information regarding a prior visit. We do not use texting for marketing purposes. Our website does not use tracking cookies.

IMPORTANT!

Thank you for applying. The charge for today's doctor visit is $159. If you're paying in cash, take the tablet back to the staff. All payments are non-refundable once you see the doctor. You will need to pay the State for the card later during your visit. Our doctor will be with you shortly.

Your Order

Today's Date *

Buyer's Email *

Billing Address *

Address Line 1

City

State

Zip Code

Payment *

Pay in Full
Pay in Cash

Pay in Full *

Price: $159.00

Cash. (Pay at front desk) *

Price: $159.00

Credit/debit card *

Card

Name on Card

Total *

$0.00

Invoice #{entry_id}

Your protected health information is always kept safe, confidential, and private. - Privacy Policy