Patient Registration – Humboldt Patient Resource Center

Name*
First Last
Date of Birth*
City of Residence*
Phone*
Email*
Sex*
- Male
- Female
How Did You Hear About Us*
- Weedmaps
- Leafly
- Google
- Emerald Magazine
- Word of Mouth
- Other
Please select all that apply
Please list any known allergies
Medical History*
- Anxiety
- Appetite
- Convulsions
- Digestive Issues
- Fatigue
- Insomnia
- Muscle Spasms
- Nausea
- Neuroprotectant
- Pain Relief
- Vomiting
- Other
What symptoms do you use medical cannabis for?
Have you ever had an adverse reaction to cannabis?*
- Yes
- No
If so, please explain
In case of an emergency do you give HPRC permission to discuss your cannabis use with medical staff?*
- Yes
- No
Are you a
- State Card Holder
- Senior (55 years +)
- Veteran
- Student
How often do you use cannabis?*
- Daily
- Weekly
- Monthly
Are you a first time cannabis user?*
- Yes
- No
I understand that I need to bring a valid copy of my medical recommendation and valid state issued ID when I visit HPRC.
- Yes, I understand
Membership Agreement*
- I agree
I have read and agree to the Membership Code of Conduct