Haven MJD Intake Form

Medical Card Evaluation Intake Form

Complete this form after paying for your service. Your information is submitted securely to your chart. Upload your ID and health insurance card in the Optimantra Patient Portal.

Patient Identification

First Name *

Last Name *

Date of Birth (DOB) *

Social Security #

Medical Card Number (if renewing or transferring)

Patient Status

Home Mailing Address

Full Mailing Address *

Health Insurance Information

Please upload a copy of your insurance and ID card in the Patient Portal.

Insurance Name

Group Number

Member ID

Medical Condition / Diagnosis

What is your medical condition or diagnosis for the use of medical marijuana? *

Dosage and Product Preferences

Medical Marijuana Usage: Maximum Daily Dose: 350 mg

Route	mg/day	Max
Inhalation		350
Edibles		60
Oral		200
Topical		150
Sublingual		190

Smoking/Flower Amount (oz/day) — Max: 2.5 oz/day

Would you like to request more than the standard limit (up to 4 oz/day)?

Patient Signature

Patient Signature (typed name) *

Date *

571 Ave K SE Winter Haven FL 33880 • Phone: 407-440-0708 • Fax: 407-357-0347