Medford Intake Form

First Name

Last Name

Today's Date

Office Location

Mailing Address

Physical address

City, State, and zip code

Mobile Number

Email Address

Home Number

ODL/ID#

Date Of Birth

Male/Female

Male

Female

Married/Single

Married

Single

Have you been seen here before:

Yes

Have you ever had an Oregon Medial Marijuana Card:

Yes

If yes, when did/do you expire?

How did you hear about us?

Patient has read and completed Intake Form Truthfully and understands that appointment cancellation needs to be 24 hours prior to appointment or fees will be charged

Signature of Client/Patient:

Today's Date