Medical Marijuana, Philadelphia, PA | Cannabis Products Devon, PA

Patient Information

Name*

First Last

Date of Birth*

Sex*

Male
Female

Preferred Pronoun

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Has caregiver?

I have a caregiver

Caregiver Information

Name

First Last

Date of Birth

Sex

Male
Female

Preferred Pronoun

Relationship to Patient

Phone

Email

Contact Preferences

Preferred method of contact:*

Phone
Email
Text

Sign-up for Keystone Shops Newsletter?

Yes
No

Sign-up for Keystone Shops Text Alerts?

Yes
No

Would you like to receive follow-up from Keystone Shops medical professionals?

Yes
No

How did you hear about Keystone Shops?

Name of Doctor:

Please describe how you heard about Keystone Shops:

Medical Information

Primary Qualifying Condition*

Please check the primary qualifying condition your doctor has recommended medical marijuana use for:

Current Medication(s) / Allergies*

Cannabis Experience (Past Year)*

What symptom(s) would you like medical marijuana to relieve?*

Nerve Pain
Muscle Pain
Appetite
Sleep
Nausea
Seizures
Other

List other symptoms:

Desired Use (Check all that apply)*

Morning
Noon
Afternoon
Evening
Bedtime

Desired Psychoactivity (Euphoric feeling from medical marijuana)*

None
Low
Medium
High

Medical Conditions (Check all that apply)*

History psychosis or schizophrenia
Pregnant or Breast Feeding
Allergy to cannabis
Unstable heart disease
None Of The Above

Acknowledgement

I, the undersigned, confirm that I have read and understand the following:

Cannabis is a Schedule 1 Controlled Substance. According to Federal law, it is unlawful to board a plane, cross state lines, or be on any federal land while in possession of cannabis products.
Under Pennsylvania law, it is unlawful to transfer, divert, or allow the use of, cannabis to anyone else, even another medical cannabis patient.
I understand that while my status as a patient is protected under HIPAA privacy protections, medical cannabis patients are not necessarily protected from being terminated by employers with zero drug tolerance policies if they are discovered to be using cannabis.
I understand that a record will be made of my purchases at Keystone Shops Dispensary ("Dispensary") and this data will be shared with State regulatory bodies.
I understand that I am subject to camera surveillance and recording while on the Dispensary premises.
I acknowledge Keystone Shops may call me (and leave a voicemail if necessary) for non-promotional purposes only.
I understand that using medical marijuana will impair my ability to drive a motor vehicle or operate machinery and that it is illegal to drive under the influence of medical marijuana.

Patient hereby agrees to indemnify and hold harmless the Dispensary from and against all claims, demands, damages, costs, injuries, or expenses arising out of or in any way connected with the use or misuse of medical marijuana purchased of medical marijuana.

Consent*
I have read and agree to the above.
Signature*

First Time Patient Form - NEW

Patient Information

Caregiver Information

Contact Preferences

Medical Information

Acknowledgement