Intake Questionnaire - Healthy Partners

Name *

First

Middle

Last

Date of Birth *

Email *

Confirm Email

What is Your Qualifying Condition? *

Are You Pregnant? *

Do You Use Tobacco? *

Surgical History *

Family History

Family Medical History *

	Yes	No
Heart Disease	Heart Disease Yes	Heart Disease No
Anxiety or Depression	Anxiety or Depression Yes	Anxiety or Depression No
High Blood Pressure	High Blood Pressure Yes	High Blood Pressure No
Liver Disease	Liver Disease Yes	Liver Disease No
Stroke	Stroke Yes	Stroke No
Alcoholism	Alcoholism Yes	Alcoholism No
Diabetes	Diabetes Yes	Diabetes No
Addiction	Addiction Yes	Addiction No
Cancer	Cancer Yes	Cancer No

	1	2	3	4	+5
Choose One	Choose One 1	Choose One 2	Choose One 3	Choose One 4	Choose One +5

	Not Effective	Somewhat Effective	Effective	Very Effective
Select One	Select One Not Effective	Select One Somewhat Effective	Select One Effective	Select One Very Effective

Checkboxes *

Please read and check the box

LIABILITY WAIVER AND RELEASE

In consideration of the medical evaluation to be performed by a Healthy Partners LLC physician, I, my heirs, assigns and any agents acting on my behalf, agree to release Healthy Partners LLC and any affiliated physicians, principles, agents, and employees from any and all liability, claims, damages and/or causes of action relating to or arising out of:

My use or possession of cannabis (marijuana)
Denial of patient certification or state-application for a medicinal marijuana card for any reason

I understand and acknowledge that:

Healthy Partners LLC and affiliated physicians, officers and/or agents make no guarantees or warrants that a patient will receive a physician recommendation and/or certification following their medical examination and evaluation. If a Healthy Partners LLC physician concludes that a patient is not eligible for a recommendation or certification following their examination and evaluation, that patient’s payment to Healthy Partners LLC is not refundable;
Healthy Partners LLC is not employed by, affiliated with or an agent of the State of Michigan;
Healthy Partners LLC is not a Dispensary and cannot provide me with medicinal marijuana or any other medication;
Receiving a physician's recommendation for use of medical marijuana does not guarantee that I will be eligible to obtain, possess or use medicinal marijuana pursuant to Michigan law;
Healthy Partners LLC and any affiliated physicians and/or agents make no guarantees or warrants that the use of medicinal marijuana will be effective in treating my qualifying condition;
There have been no representations made by Healthy Partners LLC or any agents acting on its’ behalf about the application or enforcement of federal law in connection with the possession or use of medicinal marijuana; and
I, my heirs, assigns, and/or agents agree to release of Healthy Partners LLC and any affiliated physicians, principles, and agents from any and all liability (to the extent permitted under applicable law) arising from or related to any of my dealings with Healthy Partners LLC.

Please sign here (with your finger or cursor) *

Date *

Attach a copy or photo of your ID (.png & .jpg only, 2MB Max) *

Click or drag a file to this area to upload.

You must be a Michigan Resident to get a MMMP Card. Acceptable forms of residency proof/ID are: Michigan Personal ID or Drivers License - OR - your out-of-state/Federal ID or Drivers License & your Michigan Voter Registration Card.

Michigan Medical Marijuana Program Patient ID Card (for renewals only | .png & .jpg only, 2MB Max)

Click or drag a file to this area to upload.

***You must upload a copy/photo of your MMMP Patient card to qualify for a Renewal Appointment.***

Family History

Marijuana Use History