Ayr CT Patient Intake
Full Legal Name
*
First Name
Last Name
Do you have a preferred name?
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Birth
Gender
*
M
F
X
Street Address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
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
2 digit month, 2 digit day, 4 digit year
Date
CT Medical Marijuana Card ID Number
*
Medical Marijuana Card Expiration
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit year
Date
Caregiver Email Address
*
Caregiver Phone Number
*
Caregiver ID
*
Caregiver ID Expiration Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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)
*
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
2 digit month, 2 digit day, 4 digit 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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