Connecticut Apointment - Simply Medical Cards

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Patient Health Questionnaire

Please provide accurate responses. All information is confidential and can only be viewed by the medical practitioner you speak with at Simply Medical Cards. Your information is protected by and subject to Federal HIPAA laws.

Required Notice: Please read our HIPAA Notice of Privacy Practices before completing this form. Federal law requires that this notice be made available to you.

Patient Information

Full Legal Name

Date of Birth

Mailing Address

Phone Number

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Qualifying Medical Condition

Please indicate the qualifying medical condition for which you would like a Medical Marijuana Card

Are you currently being treated for the condition listed above?

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Medications & Allergies

Please list medications you are currently prescribed

Please list current over-the-counter medications, vitamins, supplements, etc.

Medication Allergies

Other Allergies

Additional Information

Please provide any other information that may be helpful or that you would like to discuss with your healthcare practitioner

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Connecticut

Select Your Plan

Select Date & Time

Patient Health Questionnaire

Patient Information

Qualifying Medical Condition

Medications & Allergies

Medical History (Diagnosed, Current or Previous)

Heart Health

Respiratory

Psychiatric / Mental / Cognitive Health

Substance Use History

Additional Information

Review Your Booking

Select Payment Method

Secure Payment

Appointment Booked Successfully

Contact Information

Useful Links

Connecticut

Select Your Plan

Select Date & Time

Patient Health Questionnaire

Patient Information

Qualifying Medical Condition

Medications & Allergies

Medical History (Diagnosed, Current or Previous)

Heart Health

Respiratory

Psychiatric / Mental / Cognitive Health

Substance Use History

Additional Information

Consent & Acknowledgment

Review Your Booking

Select Payment Method

Secure Payment

Appointment Booked Successfully

Contact Information

Useful Links