Ayr CT Patient Intake
Full Legal Name
*
First Name
Last Name
Do you have a preferred name?
Birthdate
*
-
Month
-
Day
Year
Date of Birth
Gender
*
M
F
X
Street Address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
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District of Columbia
Florida
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Hawaii
Idaho
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Kentucky
Louisiana
Maine
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Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Phone Number
*
May we leave a Voicemail?
*
Yes
No
Email Address
*
Government Issue ID Type
*
Please Select
Driver's License
State ID
Passport
Please select one
ID Number
*
Government ID Expiration Date
*
-
Month
-
Day
Year
Date
CT Medical Marijuana Card ID Number
*
Medical Marijuana Card Expiration
*
-
Month
-
Day
Year
Date
Have you ever had a medical marijuana card in Connecticut?
*
Yes
No
Where was the last place you purchased a MEDICAL marijuana product in CT?
*
Name of Business and City
Are you a Veteran, Teacher, or currently working in the CT Cannabis Industry?
*
Please Select
Veteran
Teacher
CT Cannabis Industry Worker
N/A
Proof Required
Do you have a registered caregiver?
Yes
No
Caregiver Full Name
*
Caregiver Date of Birth
*
-
Month
-
Day
Year
Date
Caregiver Email Address
*
Caregiver Phone Number
*
Caregiver ID
*
Caregiver ID Expiration Date
*
-
Month
-
Day
Year
Date
What is your certifying diagnosis?
*
Please list your symptoms:
*
Please list any other health conditions:
*
Are you capable of becoming pregnant or breastfeeding?
*
Yes
No
Are you planning on becoming pregnant or breastfeeding?
*
Yes
No
Cannabis use during pregnancy or breastfeeding is not recommended by Ayr Wellness pharmacists. Please discuss all risks and benefits of cannabis use with your OB/GYN and/or the pediatrician before use.
*
I understand
Rate your familiarity with cannabis on a scale from 0 (no experience or knowledge) to 5 (no assistance needed for product selection or dose recommendations)
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0
1
2
3
4
5
Please list medications/supplements for the pharmacists to screen for cannabis interactions.
*
Would you like a phone consultation with a pharmacist?
*
Yes - We will contact you to schedule a consultation (or provide one now if you are in-store)
No
Please confirm that you would like to waive your consultation (you can schedule one in the future if needed!)
*
Yes
No
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Please read and acknowledge our Notice of Privacy Practices in its entirety.
Please read and acknowledge our Dispensary Rules in their entirety.
Print Name
*
Date
*
-
Month
-
Day
Year
Date
Signature
*
Patient ID Number
*
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I opt in to receive communication via text message to the provided phone number
*
Yes
No
I opt in to receive communication via email to the provided email address
*
Yes
No
Please sign below to acknowledge that you have read and understand Ayr's Patient Intake Form in its entirety.
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