Basic Info

First Name

Middle Name

Last Name

Date of Birth (mm/dd/yyyy)

Password

Repeat Password

Please read and accept Terms of Use to continue

I have read, agree and fully accept Heally Terms of Use

Personal

Country you are currently located in

For which state do you want a doctor evaluation

Please provide the exact address where you would like to receive your recommendation card.

Address

Apartment

City

Country

State

Postal Code

Time Zone

Phone

Gender

Medical

If you are a returning patient to marijuana doctor?*

Cell phone

What local Medical Marijuana Treatment Center (dispensary) are you ordering from?

Are you currently on probation?*

Are you currently pregnant?

Are you planning on getting pregnant?

Breastfeeding

Please select any of the following problems you have or have experienced since your last visit*

AnxietyDepressionSleep disordersChronic PainBack PainMigrainesHeadachesPanic attacksPTSDCancerEpilepsyAlzheimerHIV/AIDSGlaucomaMultiple-sclerosisParkinsonALS (Lou Gehrig’s)Crohn’sWeight lossNumbnessJoint painChest painSwelling lower ext.Shortness of breathConstipationNauseaMuscle SpasmsDiarrheaLoss of AppetiteStomach PainVomitingSwollen AnklesSkin RashHeart Burn or RefluxSeizuresEye ProblemsBlood in BowelsChillsTirednessLympha denopathyOther

Any new medical conditions?*

Do you have new medical records?*

Medications or OTC (please provide Name Dosage Frequency)

Do you currently use:

Tobacco?*

Methamphetamine?*

Opiates?*

Cocaine?*

Heroin?*

Other Street drugs?*

Are you allergic to any medications?*

Have you been hospitalized?*

Have you had surgery?*

Attending or have attended any substance abuse or rehabilitation program?*

Medical Marijuana Treatment, please provide details is your current dosage and regimen effective for your medical condition?*

What would you describe your current usage as?

What side effects, if any, have you experienced due to marijuana treatment?

Are you experiencing any benefits from using Medical Marijuana compare to your previously medical treatment?*

Have experienced an adverse drug interaction with any prescription or nonprescription medication with medical marijuana?*

What is your patient id (if available)?

I confirm that all above mentioned information is correct and true

Complete profile

Payment Details

Card:	Loading... ************
Card Holder:	Loading...
Card Expire:	Loading...

Fee charged after visit:

Please fill in your payment information. You will be charged only after your appointment is successfully completed. Please note that in order to protect your privacy the credit card line item will only state Heally Inc.

What is my CVV code?

Please fill out the form to create your user account. Note that all your information will be encrypted, secure and remain confidential.

Create an Account

Basic Info

Please fill out the form to create your user account. Note that all your information will be encrypted, secure and remain confidential.

Create an Account

Basic Info

Personal

Please provide the exact address where you would like to receive your recommendation card.

Medical

Complete profile

Payment Details

Fee charged after visit:

Please fill in your payment information. You will be charged only after your appointment is successfully completed. Please note that in order to protect your privacy the credit card line item will only state Heally Inc.

E-Sign

Please review and e-sign the medical form you have just completed: