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VIRTUAL VISIT
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PATIENT INFORMATION

Patient Informationnno1naf08N2019-04-18T15:24:22-05:00

Please fill out the information below to prepare for your appointment.

PATIENT INFORMATION FORM

I attest under penalty of perjury that I am the individual that I have identified myself as, and I am entering into an agreement with 'Dynamic Medical Wellness, in exchange for an evaluation, and/or treatment, and/or recommendation that is necessary for my medical condition(s). In doing so, I acknowledge willfully, of sound mind and body, that in exchange for these services I am transmitting my personal, protected, and private health information (PHI) over an unsecured and non-HIPPA (Health Information Portability and Privacy Act) internet connection for the purposes of my medical needs. I attest that I fully understand that my information could potentially be compromised by a malicious third party, but I also attest that I will indemnify and hold non-responsible the "owners," "Physicians," "Employees," "Fiduciaries," and/or any of the aforementioned 'Family Members," and/or "Beneficiaries," harmless if such an untoward event were to occur. I am attesting to this statement explicitly and wish to enter into this agreement without duress or coercion for my own medical care.
Agreement to use website*
- By Checking this box I have read and understand the above statement and agree to use this website
How did you hear about us?*
- Online (Please Choose Below)
- Newspaper
- Referral From a friend
- Other
Online Sites
Other
Name*
First Middle Last
Date*
Physical Address*
Street Address City State ZIP Code
County of Residence*
Mailing Address (if different than Physical Address)
Street Address City State ZIP Code
Email*
Phone*
Gender*
- Male
- Female
Age*
Marital Status*
- Single
- Married
- Separated/Divorced
- Widowed
Are you Pregnant? (required or N/A)*
Allergies? (required or N/A)*
Have you had a Medical Cannabis License in another state?*
- Yes
- No
If yes, what State?
State
Medical History*
Surgical History*
Family History*
Tobacco Use (all forms)*
- Yes. Currently
- Yes. Previously
- No, Never
If yes, amount per day and number of years
Alcohol consumption per week*
- 0-5 drinks per week
- 6-10 drinks per week
- 10+ drinks per week
History of Substance Abuse*
Reason(s) you are pursuing a Medical Cannabis License*
Other treatments attempted for relief?*
Current Medications*
Government Issued PHOTO ID* File upload
General Consent for Care and Treatment Consent TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below, you are indicating that
1. you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and
2. you consent to treatment at this office or any other satellite office under common ownership.
The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions. I voluntarily request a physician, and/or midlevel provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Care and Treatment Consent*
- By Checking this box I agree to the Care and Treatment Consent as Outlined Above
HIPPA Compliance Patient Consent Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, and if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon the execution of this consent.
HIPAA Compliance & Privacy Policies*
- By Checking this box I acknowledge that I understand and have been informed of this Medical Practice's Privacy Policies
Release of Liability I thoroughly understand that I must be able to provide proof of identity and proof that I have a residence in the State of Oklahoma, in order to obtain an approval or recommendation for a Medical Cannabis License (medical marijuana) as dictated by legislation governed by the Oklahoma Medical Marijuana Authority (OMMA). (OAC 310: 681) I understand that the physician does NOT make any final approval of applications submitted for an Oklahoma Medical Cannabis License and that I, the patient, must personally submit my application online, within thirty (30) days of a physician's authorization, along with all of the required appropriate supporting documentation, a picture, and the required license fee in order for the OMMA to evaluate issuing me a Medical Cannabis License as dictated by legislation. (OAC 310: 681) I fully affirm that I have a SERIOUS medical condition that adversely affects my quality of life. I have found or am interested in finding out whether cannabis (medical marijuana) provides substantial relief and improvement in my condition. I thoroughly understand that the cannabis plant is not regulated by the United States Food and Drug Administration {FDA), although it is regulated by the Oklahoma Medical Marijuana Authority (tentatively beginning 5/1512019). In requesting approval or recommendation for a license to use this plant as medication, I assume full responsibility for any and all risks (medical, occupational, etc.) of this action. I have been thoroughly advised that cannabis (medical marijuana) smoke contains chemicals known as tars that may be harmful to my health. Should respiratory problems or other ill effects be experienced in association with its use, it should be discontinued and reported to the physician. I have been thoroughly advised that the use of cannabis (medical marijuana) may affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my elective use of cannabis. The OMMA according to OAC 31 O: 681, provides for the possession and cultivation of cannabis (medical marijuana) for the personal medical purposes of the patient with a physician recommendation. It was made absolutely clear to me, the patient, that the physician, staff and representatives of this practice are neither providing cannabis nor are they encouraging any illegal activity in my obtaining cannabis (medical marijuana). I thoroughly understand if I have any questions regarding the legality of an activity involved in my use of cannabis (medical marijuana), that it is my responsibility as the patient to visit the OMMA website where the answers to such questions may be obtained. I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal cannabis treatment. I understand that no claims about the medical efficacy of cannabis will be made by the physician. The physician, staff, and representatives are addressing specific aspects of my medical care, and, are in no way establishing themselves as my primary care provider. Should an approval be made for my medicinal use of cannabis, I understand that there is a renewal date of two (2) years on the license. I understand that it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the initial approval. Furthermore, I the undersigned patient, my heirs, assigns, or anyone acting on my behalf, holds the physician and his/her principals, agents, employees, and clinic absolutely free of and harmless from any liability resulting from the use of cannabis.
Release of Liability*
- By Checking this box and providing my full legal name below I acknowledge the entirety of the Medical Cannabis Release and all of it's tenants explicitly.
Full Legal Name (eg first, middle, last)*
Today's Date*
Name
This field is for validation purposes and should be left unchanged.

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CALL US 405.276.8079

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