Events Form - Elevated Health MD

Upload Front and Back of Your Driving License *

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List Your Conditions & The Date You Were Diagnosed

Check all that apply to you. Must select at least (1) one. *

1

Note To The Doctor

Briefly tell us about your qualifying conditions you selected above. (Ex. "Severe Chronic Pain.") *

Do you have Medical Records?

(They are not required) *

Yes No

If available upload medical records here.

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Name of Your Primary Care Physician

Have You Ever Had a Med Card Before? *

Yes No

If Yes, Please Provide Expiration Date

If Yes and Card is Not Expired Please Provide PIN #

List any medications you are currently taking

Please list any recent surgeries or hospitlizations.

What are the medical reasons you are applying for the card? Please describe *

By signing below, I attest that I have been advised by ElevatedHealthMD that the use of cannabinoids and THC containing products have not been approved by the FDA and the clinical benefits are unknown and may cause harm. I am voluntarily agreeing and consenting to treatment through the use of cannabinoids and THC containing products and waive any rights to actions against the physician and the State of Georgia for the use of cannabinoids and THC containing products *

I agree to the Terms & Conditions & Privacy Policy provided by Elevated Health MD. I agree to receive communication and notification from Elevated Health MD. *

Password should contain minimum 8 characters.

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