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Moondance Medical Qualification Form

Type of phone number:
Preferred Method of Communication:
How did you find us?
Are you a current Missouri Resident?
Do you have a valid Missouri Drivers License or Photo I.D.?
Are you 18 years of age or older?
Do you currently have medical records and/or documentation from a primary care physician or specialist describing the diagnosis?
Are you currently receiving care for your applicable condition(s) by another physician?
Are you pregnant or breastfeeding
Are you now or have been treated for Bipolar or Schizophrenia?
Are you currently seeing a Physician?
Is the patient currently on probation or parole?
Has the patient ever been arrested or convicted for a crime relating to marijuana specifically drug trafficking?
Does the patient have a current CDL (commercial driver's license)?
Do you have any other federal licenses (eg. pilot's license, government security clearances, etc.)?
Have you been recommended medical marijuana in the past?
Intake Form
Referred By:
Are you currently taking any prescription medications?
Your Symptoms (check all that apply)
Nicotine Use
Nicotine Use
Chronic Pain
Have you had persistent pain for more than six weeks?
Does your pain Interfere with pleasurable activity?
Does your pain limit your ability to work?
Have you had Nerve Blocks/Epidural?
Have you had Osteopathic/Chiropractic treatment?
Have you had Physical Therapy?
Have you had TENS (transcutaneous electrical nerve stimulator)?
Have you had Acupuncture?

Thanks for submitting!

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