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Are you a New or Renewing patient for Medical Cannabis?*

Renew New

Are you physically waiting at the dispensary? *

Yes No

Personal Information You selected a booking for Louisiana Certification by Next Available Provider. Providing accurate personal information is essential to ensure your certification process goes smoothly.

First Name*

Middle Initial

Last Name*

Full Name must match your state ID Card: such as a drivers license or you may be rejected at your dispensary

Email*

Confirm Email*

No appointment confirmation or Approval email will be sent if email is incorrect

Phone Number*

Confirm Phone Number*

You will NOT recieve an appointment call if number is incorrect

Date of birth*

Suffix (Jr, Sr, I, II, III, IV)

Drivers License / ID Number

Address Please ensure the address you provide matches the one on your state ID to avoid any delays or discrepancies during the certification process.

Street Address*

City*

State*

Zip Code*

Apt, Unit, Lot, etc

Patient Intake Form Accurate health information is crucial for the doctor to make informed and effective medical decisions regarding your care.

Qualifying medical condition (choose one)*

Are you physically disabled?*

Yes No

What was your gender at birth?*

Male Female

Do you currently have, or have you ever had, schizophrenia, psychosis, or any suicidal thoughts or ideation? *

Yes No

Were you diagnosed with Bipolar? *

Yes No

Are you currently taking opioids or any pain medications? *

Yes No

Have you been hospitalized or had any surgeries in the last 6 months?*

Yes No

Are you currently taking any prescription medications? *

Yes No

Do you have any allergies to any medications?*

Yes No

Do you currently use any tobacco products?*

Yes No

Do you currently drink alcohol?*

Yes No

Are you currently using any cannabis products?*

Yes No

Dispensary of choice?*

How did you hear about us?*

Do you accept the Terms and Conditions, Liability Waiver, and Medical Release Authorization?