Is Medical Marijuana Right for you?

Please fill this form out to the best of your ability and the staff at the Office of Dr. Moskowitz will get in touch with you within 24 hours. We look forward to working with you on your journey to health and relief!

Mark the medical conditions that apply to you or the patient

	-
Chronic Pain	-
Cancer	-
HIV infection or AIDS	-
Amyotrophic Lateral Sclerosis (ALS)	-
Parkinson's Disease	-
Multiple Sclerosis	-
Epilepsy	-
Inflammatory Bowel Disease (IBD)	-
Neuropathies	-
PTSD	-
Huntington's disease.	-

Do you have a history of any of Psychosis, schizophrenia or unstable psychiatric disease such as manic depressive illness *

Yes

No

Personal Information

First Name *

Last Name *

Date of birth: +

Gender

Street Address

Address Line 2

City

State

Zip Code

Phone Number *

Email Address *

Name of Insurance *

Medical Files - Upload Medical Documents

Do you have Medical Records that discuss your medical diagnosis/condition *

Yes

No

If available, kindly upload or fax us any available medical documents related to you r current medical diagnosis condition. This will remain confidential and will only be used to determine your eligibility.

I am completing this form for someone other than myself.