Web. 1st Card (bgn)$125 - First Card Online Deal in Miami649 NE 79 ST Miami, FL 33138 Call ahead - 786.953.6838This form is for 1st time FL card applicants. Complete each step in the form below.Schedule your visit date.Pay $125 online now and save, a lot. (In-person cost is $159) Fast. Easy. Card.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 10Ever apply for a Florida med card before? *NoYesSTOP HERE. This online application is only for those who have never previously applied for a Florida marijuana card. If you have applied for a med card in the past, go to Renew Your Medical Card Online in Florida. If you are a KindHealth patient already, re-apply at Marijuana Card Renewal Online. Call (786) 953-6838 for more information.Today's date *SSN **Required for the Medical Marijuana Use RegistryFL Driver's license # or State ID # **Required for the Medical Marijuana Use RegistryDATE OF BIRTH *First Name *Last Name *PHONE *Email *EmailConfirm EmailNextFLORIDA ADDRESS *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeFL County *Miami-DadeBrowardAlachuaBakerBayBradfordBrevardCalhounCharlotteCitrusClayCollierColumbiaDesotoDixieDuvalEscambiaFlaglerFranklinGadsdenGilchristGladesGulfHamiltonHardeeHendryHernandoHighlandsHillsboroughHolmesIndian RiverJacksonJeffersonLafayetteLakeLeeLeonLevyLibertyMadisonManateeMarionMartinMonroeNassauOkaloosaOkeechobeeOrangeOsceolaPalm BeachPascoPinellasPolkPutnamSanta RosaSarasotaSeminoleSt. JohnsSt. LucieSumterSuwanneeTaylorUnionVolusiaWakullaWaltonWashingtonWeight (lb) *Age *Sex Assigned at Birth *MaleFemalePREGNANT or PLANNING to be? *NoYesAre you currently breast feeding? *NoYesWas last cycle over 28 days ago? *NoYesWhy was your cycle late? *MenopausePerimenopauseHysterectomyI may be pregnantOtherPlease explain *PreviousNextGENERAL MEDICAL HISTORY (check all that apply)sweatsweight changeinsomniafatiguemigraine/headachesleeping problemsRespiratoryasthma/wheezecough/sputumbronchitisCOPDCOVID-19short of breathHeart DiseaseStrokeblood clotsabnormal heart beatAnginaCADchest painGastrointestinalnausea/vomitingabdominal painswallowing problemschange appetitechange bowel habitsheartburnBones /Jointsback/neck painstiffnessswellingGoutarthritispainPreviousNextPsychologicalAnxiety/nervousnessmood swingsSchizophreniaDepressionADHD/ADDBipolarPTSDdelusionshallucinationsEndocrineDiabetesHyperthyroidHypothyroidPancreasAdrenal glandsFlorida Qualifying Conditions (check any that apply)Hepatitis CCancerMultiple sclerosisCrohn's diseaseEpilepsyHIV/AIDSParkinson diseaseGlaucomaALS (Lou Gehrig's)Muscular dystrophyTerminal illnessPost-traumatic stress (PTSD)Other or similar conditions. Choose all that apply (if more than one, ctrl + click)NoneAlzheimer'sCerebral PalsyDegenerative Disc DisorderFibromyalgiaHerniated DiskIrritable Bowel SyndromeLupusLyme DiseaseMuscle SpasmsMyasthenia GravisMyositisNeuropathyOsteoarthritisOsteoporosisPeripheral Vascular DiseasePolymyalgia RheumaticaPost-Polio SyndromePsychiatric ConditionsReflex Sympathetic DystrophyRheumatoid ArthritisRLS (Restless Legs Syndrome)ScoliosisSeizuresSickle Cell AnemiaSpasticitySpinal StenosisTourette'sUlcerative ColitisWhat treatments have you used?What types of treatment have you taken for your medical condition in the past?PreviousNextHAVE YOU USED MARIJUANA? *NoYesHow have you used it? *FlowerVapeOilEdiblesTopicalsConcentratesWhat types? *SativaIndicaHybridMore than one typeI don't knowHow often? *less than once/day1-3 times/day4-5 times/daymore than 5 times/dayHow well did it work? *Extremely wellVery wellModerately wellSlightly wellNot at allDo you get any side effects? *NoYesList cannabis side effects *PreviousNextTAKE ANY MEDICATIONS? *NoYesList the medications you take *Do you have any drug allergies? *NoYesList of drug allergies *Any alcohol/drug/substance abuse? *NoYesIf yes, please explain *Do you take any blood thinners? (Check all that apply)AspirinCoumadinPlavixPersantineXareltoHow did you hear about us? *internetdrive-byfrienddispensarylocal businessradio/newsotherGDPR Agreement *KindHealth may store my information for this transaction. PreviousNextPatient Attestation - 1 minute readHideShowPATIENT ATTESTATION. I attest that I am a Florida resident and the information on this form is correct. Any and all medical history, presented or omitted, is factual and complete to the best of my knowledge. I do not plan or intend to use my physician’s recommendation for purposes of illegally obtaining, growing, or distributing medical marijuana. I am aware that the KindHealth doctor will revoke my recommendation and legal actions will be taken if it is found at any time that I have perjured or misrepresented myself or my condition, intentions, or falsified any medical records to the physician. I have read and understood this attestation. DO NOT SUBMIT THIS FORM IF YOU DO NOT UNDERSTAND AND AGREE WITH THIS ATTESTATION. Review Patient Attestation *I have read, understood and agree with the patient attestation.PreviousNextRelease of Liability - 5 minute readHideShowRELEASE of LIABILITY I attest that I am a Florida resident and the information on this form is correct and any medical history presented or discussed with the doctor is all factual and complete to the best of my knowledge. I do not plan or intend to use my physician’s recommendation for purposes of illegally obtaining, growing, or distributing medical marijuana. I am aware that the KindHealth doctor will revoke my recommendation and legal actions will be taken if it is found at any time that I have perjured or misrepresented myself or my condition, intentions, or falsified any medical records to the physician. Solely for verification purposes, I authorize the KindHealth staff/contracted doctors to converse regarding my medical condition. I understand the United States Food and Drug Administration does not regulate cannabis and it may therefore contain unknown quantities of active ingredients, impurities and/or contaminants. I understand the potential risks associated with an elevated daily consumption of medical marijuana including risks with respect to the effect on my cardiovascular, pulmonary systems and psychomotor performance. There are also risks associated with the long-term use of marijuana as well as potential drug dependency. I am aware the benefits and risks of using marijuana are not fully understood and may involve risks not yet identified. In requesting an approval or recommendation for the use of medical marijuana, I assume full responsibility for any risk involved in this action. I understand medical marijuana smoke contains chemicals known as tars that may be harmful to my health. Research indicates that vaporizing cannabis may eliminate exposure to tar. If I experience any respiratory problems or other ill effects be experienced in association with its use, I should discontinued its use and report to the physician immediately. I am advised the use of medical marijuana might affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my cannabis use. Florida’s Medical Marijuana Legalization Initiative - Amendment 2, approved November 08, 2016 provides for the possession of medical marijuana for the personal medical purposes of the patient with a physician approval or recommendation. KindHealth staff, physicians and/or representatives are not providing medical marijuana, nor are they encouraging any illegal activity in my obtaining medical marijuana. I attest that I am not a member, employee or agent of any media or law enforcement agency. It is illegal to film or record in this office with a video camera, cell phone or any other recording devise be it a still image, video or audio. This is a direct violation of HIPAA regulations and patient/doctor confidentiality. I, the undersigned, I affirm that I have a serious medical condition that negatively affects my quality of life. I found, or am interested in finding, whether or not medical marijuana provides substantial relief and improvement in my condition. I hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal marijuana treatment. The physician, staff, and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider. I realize I am paying KindHealth for an evaluation to assess my eligibility for the OMMU Registry. This evaluation may find my condition as not appropriate for Florida state certification. In the case you are not found eligible, there is no refund to you as our staff has performed its medical service appropriately. In short, I am paying KindHealth for the service, not a guaranteed eligibility. Should an approval be made for my medicinal use of marijuana, I understand there is a renewal date specified by the physician depending on the condition. I understand that it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval. Flower Given the potential adverse effects of smoking marijuana flower, the FL Board of Medicine requires doctors have patients use a vapor method of inhalation before advancing to flower. Purchase of a vape pen from the MMTC serves as ‘proof of vaping.’ If you then have vape pen related side effects, such as a cough, sore or harsh throat, only then can the ordering doctor add flower to your prescription. This purchase helps fulfill the requirement for both the state and doctor. I have been shown a copy of the KindHealth Notice of Privacy Practices for my review. By signing this form, I am consenting to KindHealth’s use and disclosure of my PHI in accordance with those terms. Furthermore, the undersigned, or anyone acting on my behalf, agree to hold the physician and his/her principals, agents, and employees, free of and harmless from any liability resulting from the use of medical marijuana.Review of Release of Liability *I have read, understood and agree with the patient attestation.PreviousNextNotice of Privacy Practices - 4 minute readHideShowNOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. KindHealth Assurance KindHealth is committed to ensuring your health information is secure, and we protect your anonymity and privacy. We put physical, electronic and managerial procedures in place to safeguard and secure any data you provide us. What is Protected Health Information? Health information is any information about you, in any form that we either create, or receive from outside sources. This Notice of Privacy Practices refers to all health information as protected health information or “PHI”. Individually identifiable PHI includes health and demographic information collected from you which can reasonably be used to identify you. PHI and the Law Both state and federal law require KindHealth to limit the manner it uses or discloses information about a patient or a patient’s PHI in order to maintain your privacy. In addition, we are required to provide you with this privacy notice setting forth our legal duties and obligations, and your rights with respect to your PHI. All KindHealth care professionals and staff providing services in our practice are subject to this Notice of Privacy Practices and we may update the Notice from time to time, in which case we will prominently display the updated version. Uses and Disclosures of Your PHI This list is not all-inclusive. KindHealth uses any information you provide to us only in accordance with this Notice of Privacy Practices. KindHealth uses any information you provide to us only in accordance with this privacy statement. If you are an existing patient, you have already signed a consent. We will ask you to sign a consent if you are a new patient. The consent will allow KindHealth to use and disclose your PHI for your treatment, to obtain payment for the services we render to you and to assist us in our healthcare operations. We may use or disclose your PHI for your treatment or payments. Treatments:KindHealth may disclose and verify me as a patient to any law enforcement agency, my physician(s), Child Protective Services or any State approved dispensary.Validate my status as a patient using the Medical Marijuana Use Registry online patient verification system.Our medical records personnel may review your chart to ensure proper placement of all lab and other tests results in your chart prior to your visit.Our medical staff or physicians may communicate with laboratory or other testing facilities to review test results prior to your visit.KindHealth staff and doctors may discuss your case among themselves or review your medical treatment with referring physicians or physicians to whom they have referred you for care.Personnel in this office may discuss your medical information with a hospital or other healthcare facility treating you or we may discuss this information with another healthcare provider who is treating you at such a facility.This practice may announce the names of patients in the waiting area, and others may hear your name.This practice may leave VMs on your home answering machine, or send postcard or email appointment reminders.This practice may disclose health information to a dispensary when we order a prescription for you.This practice may send you information about other health-related benefits and services that may be of interest to you.Payment Delinquency:This practice may provide consumer-reporting agencies with credit information regarding your payment history.This practice may provide information to collection agencies, our attorneys, or in a legal action for purposes of obtaining payment of delinquent accounts. A printed copy of this form is available on request. I understand that KindHealth reserves the right to make changes to the terms of its Notice of Privacy Practices. I have read and understood the above Notice of Privacy Practices. Review of Privacy Practices *I have read, understood and agree with Privacy Practices.PreviousNextSign up for 7-month visit reminders by text message (HIGHLY RECOMMENDED)Consent to receive text message reminders *YES. TEXT my 7-month visit reminders. Cancel at any time.No. I do not wish to receive text message reminders.SMS Terms of Service / Privacy PolicyHideShowSMS TERMS of SERVICE KindHealth uses SMS/text messaging to send patients upcoming visit reminders. By opting-in to our SMS subscription tool, you agree to receive recurring text reminders for your scheduled visits. You may opt-out at any time by replying "UNSUBSCRIBE" to the text field. While we do not charge for this service, you may be responsible for charges and fees associated with text messaging imposed by your wireless provider. To the extent permitted by applicable law, you agree that we will not be liable for failed, delayed, or misdirected delivery of any information sent through the service, any errors in such information, and/or any action you may or may not take in reliance on the information or Service. If help is needed, type "HELP" into the text field, or call us at (786) 953-6838 and one of our team members will assist you as soon as possible. SMS PRIVACY POLICY Your right to privacy is important to us. Your SMS number remains protected health information and we do not share it with any third party entities. We use this information solely to send you text notifications for your scheduled upcoming doctor visit, or to relay follow-up information regarding a prior visit. We do not use texting for marketing purposes. 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