Coming in for the first time?

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To help expedite your first visit, and to reduce paper consumption, you may begin the new patient intake process by completing the form below.

Patient Information

Certifying  Physician Information

Additional Information

Have you used Cannabis in the past?

If yes,

Do you use Cannabis now?

How did you hear about us?

Signature

Have A Heart Cincy is not liable for any harm resulting to me and/or other individuals as a result of my medical cannabis use. Possible side effects of medical cannabis can include, but are not limited to: increased heart rate, euphoria, dysphoria, confusion, low blood pressure, dizziness, sedation, inability to concentrate, anxiety, over-eating, impairment of short term memory, and impairment of motor skills. By purchasing medical cannabis from Have A Heart Cincy, I agree to

remain in compliance with the Ohio Medical Marijuana Control Program.

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