Admissions – Cannabis Project

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GREECE: +30(690)728-2236
USA: +1(720)706-7610
WhatsApp: +30(690)727-9644

PATIENT INTAKE FORM

Please answer the questions below to your best ability. If you have any questions , please contact us by either emailing us at : [email protected] or calling us at +30(690)728-2236

Patient's Name*
Phone Number*
Your Email*
Date of Birth of Patient*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Sex*
Martial Status*
Do You have Any of the Following Health Issues? (please check all that apply)*
- High blood pressure
- Heart disease
- Lung Issues
- Hepatitis
- Fungus
- None of the above apply
Do you take any medications? If yes, please list all below and the reason each was prescribed*
Do you have any allergies? If yes, please list all below*
Have you had any past surgeries?*
When was the last time you visited a doctor?*
Do you drink/consume any of the following items?*
- Coffee
- Alcohol
- Tea
- Smoke
- Other
Occupation*
In case of an emergency, please list the name and phone number of your emergency contact*
How did you hear about our practice*
- Sun-Sential Ad
- Facebook Page
- Through a Friend
- Internet Search
Government ID*
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Consent*
I read and accept the: Terms & Conditions.