Request Appointment – Cannabis Medical Clinic

DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1.

Please fill out your info below to request your appointment to receive medical MMJ prescriptions in Texas from our doctors. A member of our team will be contacting you within the next 1-2 business days to set up an appointment.

Patient Contact Information

Patient's Name(Required)

First Last

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Gender(Required)

Female

Male

Address(Required)

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Appointment Details

Reason for Appointment(Required)

Please attach proof of your qualifying condition (if you have it): Office visit notes, screenshots of your diagnosis or proof of pertinent medications.

Upload Proof of Qualifying Condition

Drop files here or

Max. file size: 512 MB.

Office visit notes, screenshots of your diagnosis or proof, medical history, etc.

Upload a Copy of Your Driver's License(Required)

Max. file size: 512 MB.

Acknowledgments of Disclosure and Informed Consent(Required)

Yes, I acknowledge and agree to the following Medical Marijuana Patient Agreement

Medical Marijuana Patient Agreement: Please read and choose YES to indicate that you understand and agree with the information relating to Medical Marijuana (sometimes referred to as “Cannabis”). Do not sign this agreement and do not use Medical Marijuana if you have questions about or do not understand the information below.

Acknowledgments of Disclosure and Informed Consent

I understand that I am being evaluated for a physician’s recommendation for Medical Marijuana and that the physician will make this order based, in part, on the medical information I have provided. I have not misrepresented my medical condition to obtain this recommendation and it is my intent to use Medical Marijuana only as needed for the treatment of my medical condition.

I understand side effects of Medical Marijuana can include but are not limited to: Memory loss, Irregular heartbeat, Slower reaction time/inability to concentrate, Poor physical condition, Cough/bronchitis/shortness of breath, Dizziness, Impaired vision, Drowsiness/fatigue/abnormal sleep, Depression, Laryngitis, Low blood pressure, Impairment of motor skills, Anxiety/Nervousness, Dry mouth, Suppression of immune system, Hunger/Loss of appetite, Dependency, Confusion, Feelings of euphoria, Headache/nausea/vomiting, Numbness, Agitation, Paranoia/psychotic symptoms, Sedation.

I understand Cannabis may have intoxicating effects and has not been analyzed or approved by the United States Food and Drug Administration (“FDA”) and was produced without FDA oversight for health, safety, or efficacy.

Cannabis may contain unknown quantities of active ingredients, impurities, or contaminants.

I understand that the efficacy and potency of Cannabis may vary widely depending on the Cannabis strain and ingestion method.

I understand that women should not consume cannabis products while planning to become pregnant, during pregnancy or while breast feeding.

I understand that when Cannabis is eaten or swallowed, the intoxicating effects of this drug may be delayed by two or three hours or more.

I understand that there exists the possibility of becoming dependent on Cannabis and that I may experience withdrawal symptoms when I stop using Cannabis.

I understand that I may develop a tolerance to Cannabis. This means higher and higher doses might be required to achieve the same symptom relief.

I understand that a recommendation for medical marijuana does not provide me with any legal protection relating to the cultivation and/or processing of marijuana.

I understand that Cannabis may exacerbate schizophrenia or bipolar disorder in persons predisposed to those disorders.

I understand that women should not consume Cannabis products while planning to become pregnant, during pregnancy, or while breast feeding.

I understand that using Cannabis while under the influence of alcohol is not recommended and may have unexpected and dangerous side-effects.

I understand that the use of Cannabis may affect coordination, cognition, and judgement.

While under the influence of Cannabis, I will not drive, operate machinery, or engage in potentially hazardous activities.

Terms & Conditions(Required)

I have read and accept the Privacy Policy and Terms & Conditions

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