New Patient Registration Please select location? Cleveland Hts Columbus Bedford Name(Required)(As listed on card) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)Check one or more options that reflect your gender. Male Female Non-Binary Transgender Intersex Gender Non-Conforming Phone(Required)Email(Required) Address*Your address must match the address on your driver’s license. If they differ, please provide verification of current address (utility bill, lease, paystub, etc) at your next visit. 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Yes No Describe your current level of comfortability: I’m ready for the menu, please! I have a couple questions, but am somewhat familiar. Help me, please! Would you like a consultation with a pharmacist? Yes No Troublesome Symptoms?Select all that apply Anxiety/Stress Pain in joints Vision Problems/Eye Pain Loss of Appetite/Weight Loss Dizziness Skin Rash Seizures/Convulsions Depressed Feelings Muscle Pain Nerve Pain Muscle Spasms Numbness or Tingling in Limbs Trouble Sleeping Nausea/Vomiting Chronic Cough Urinary Problems Tremors Please describe which best describes you: This is my first time at a dispensary in Ohio. I have been to other dispensaries in Ohio. How would you feel comfortable using medical marijuana? Inhaled flower Inhaled oil (cartridges), Inhaled concentrate products Edible products Tinctures/Oil drops Transdermal patches Topical creams/Lotions What is/are your main goal(s) for medical marijuana therapy? How would you prefer to be contacted? Email Text Would you like to receive emails regarding store, promotional, and product updates? Yes No How did you hear about Amplify? Online search Flyer or print advertisement Word of mouth Email/Text Another Amplify Patient Please type the name of the person who referred you below: Patient and Disclosure Agreement(Required) By checking here, I attest to have read and agree to Amplify's Patient and Disclosure Agreement
