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Personal

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Medical

What is/are the main medical problem(s) which you currently have or have had in the past?*:

HIV/AIDSNauseaFibromyalgiaSeizuresArthritisMuscle SpasmMigraine HeadachesAnxietyChronic PainGlaucomaCancerTrouble SleepingLoss of AppetiteWeight LossOther

Are you RENEWING your recommendation (Have you had a recommendation in the last 10 years)*:

Do you currently use specific medications for your medical condition?:

Are you taking any prescription medications or herbs? *:

Do you have any allergies to any medications? *:

Have you ever had any surgeries or been hospitalized?:

Do you exercise?:

Do you smoke tobacco?:

Do you drink alcohol?:

Are there health/medical problems that occur frequently in your family?:

Have you experienced or been diagnosed with any of the following *:

DepressionBipolar DisorderSchizophreniaSuicidal thoughtsADHDNone

Are you pregnant? *:

Breastfeeding?:

Do you have a primary care provider? *:

When was the last time you saw your doctor/specialist about these complaints? (mm/dd/yyyy)

If available, you will have an ability to upload to your portal previous Recommendation or any other medical records as related to the medical condition(s) identified above.

Provide details on the medical condition and diagnosis:

What medical condition qualifies you for medical cannabis in Texas? *:

NeuropathySeizure Disorder/EpilepsyALSMultiple sclerosisCancerAutism/spectrum disordersDementiaParkinson's diseaseBrain Injury/Trauma (repeated head trauma from sports/other causes)Muscle Spasm/Spasticity

First time or follow up visit? *:

List Medications you currently use for your qualifying condition *:

What medications have you used in the past for your qualifying condition *:

List all other prescription medications and herbs you currently take *:

Medical Records

You will have the opportunity to upload all relevant documentation and submit it ahead of your appointment. Relevant documentation may include notes, recommendations from your primary care physician, prescriptions, and all relevant available medical records.

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Fee charged after visit:

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Basic Info

Please fill out the form to create your user account. Note that all your information will be encrypted, secure and remain confidential.

Create an Account

Basic Info

Personal

Please provide the exact address where you would like to receive your recommendation card.

Medical

If available, you will have an ability to upload to your portal previous Recommendation or any other medical records as related to the medical condition(s) identified above.

Complete profile

Payment Details

Fee charged after visit:

Please fill in your payment information. You will be charged only after your appointment is successfully completed. Please note that in order to protect your privacy the credit card line item will only state Heally Inc.

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