Patient Intake — Lotus Farmacy

Lotus Farmacy · Bloom Higher

Patient intake form

Select your profile type below. All fields marked * are required.

Profile type

The patient is the primary profile holder.

Patient information

First name *

Last name *

Preferred name

Date of birth *

DL / State ID number *

DL / State ID expiration *

Medical card ID number *

Medical card expiration *

Phone number *

Email *

Patient type *

How did you hear about us? *

ID & card uploads

Upload all four: front and back of your state ID/driver's license, and front and back of your medical cannabis card.

State ID — front *

Click to uploadJPG, PNG or PDF

State ID — back *

Click to uploadJPG, PNG or PDF

Medical card — front *

Click to uploadJPG, PNG or PDF

Medical card — back *

Click to uploadJPG, PNG or PDF

Loyalty & marketing consent

Notes

Additional notes

Patient information

Patient first name *

Patient last name *

Patient preferred name

Patient date of birth *

Patient DL / State ID number *

Patient DL / State ID expiration *

Medical card ID number *

Medical card expiration *

Patient phone number *

Patient email *

Patient type *

How did you hear about us? *

Caregiver information

Caregiver first name *

Caregiver last name *

Caregiver DL / State ID number *

Caregiver DL / State ID expiration *

Caregiver medical card number *

Caregiver medical card expiration *

Caregiver phone number *

Caregiver email *

ID & card uploads

Upload all four: front and back of the caregiver's state ID/driver's license, and front and back of the medical cannabis card.

Caregiver state ID — front *

Click to uploadJPG, PNG or PDF

Caregiver state ID — back *

Click to uploadJPG, PNG or PDF

Caregiver medical card — front *

Click to uploadJPG, PNG or PDF

Caregiver medical card — back *

Click to uploadJPG, PNG or PDF

Patient ID uploads Optional

Upload front and back of the patient's state ID or driver's license.

Patient state ID — front

Click to uploadJPG, PNG or PDF

Patient state ID — back

Click to uploadJPG, PNG or PDF

Patient medical card — front

Click to uploadJPG, PNG or PDF

Patient medical card — back

Click to uploadJPG, PNG or PDF

Loyalty & marketing consent