Medical Intake Form

PATIENT DEMOGRAPHICS

Please complete the Medical Intake form below to determine eligibility for medical marijuana certification. A member of the NYMMA team will be in touch with you shortly with more information, next steps and to schedule your video consult with the doctor when all information is received.

Please make sure all information is entered in correctly and your first and last names match the spelling on
your NYS driver's license.
This information is used to generate your MMJ certification if you are approved to be certified. Any corrections needed to be made to the MMJ certification after it is submitted, will take 1-2 weeks.

Are you a NY state resident? Please upload proof of New York State residency (i.e. NYS driver’s license, NYS non-driver's ID, or utility bill) here. Each File Size Limit: 1MB.
‍If you do not have a NYS photo ID, please upload a document and your photo ID.

*required - please make sure your file(s) uploads successfully. If you have any issues uploading your photo ID / documents, you may also email them separately to: info@nymedimarijuana.com.

YesNo

Do you have Medical Records that evaluate your medical diagnosis/condition?YesNo

If available, please upload the latest medical documents related to your qualifying medical condition(s) in PDF or JPG format. Each File Size Limit: 1MB. You may also email them separately to: info@nymedimarijuana.com or fax to: (516) 590-0198. Your medical records will be secure and confidential and will only be used to determine your eligibility for medical marijuana certification.

If you do not have your medical documentation, our team can retrieve your medical records for you.

We will email you a HIPAA Medical Release form for you to complete, sign and send back to us. Please enter the full name and phone number of the medical provider whom you've treated with, who is most relevant to your qualifying condition.