To make an appointment you must be at least 18 years of age.

Appointment Request Form

Please complete the form below. * All Fields are Required
This transmission is confidential and subject to HIPPA privacy regulations
  • (XXX) XXX-XXXX
  • Please enter your email address twice for verification.
  • XXXX
  • This field is for validation purposes and should be left unchanged.

What to Bring to your Appointment

NEW PATIENTS:

1. Medical Records

The records do not have to be extensive, but should satisfactorily document the medical condition for which you wish to use medical marijuana. The records should clearly state a diagnosis, detail any tests performed, and indicate treatment prescribed. Please see complete details in in the Medical Records section.

Please be advised that it may take up to thirty (30) days to obtain your medical records and there may be a charge for the records from your provider. Please do not mail them to our office. Please bring a copy with you to your appointment.  If required, or possibly to avoid any charge for the records, you can fax the records to (815) 366-7913. It is preferable to bring the records with you. PLEASE DO NOT STAPLE RECORDS TOGETHER AS THEY WILL BE SCANNED AND RETURNED TO YOU.

2. Print out, read and complete the following two (2) Patient Forms and bring them to the appointment:

Also please review the form entitled Medical Marijuana Benefits and Risks (PDF) before your appointment.

Completing the forms in advance will save you about 30 minutes during the appointment.

3. Picture Identification

Driver’s license   or  Picture ID with proof of residency   (e.g.: utility bill in your name).

4. The last four digits of your social security number.

Please note our fees and cancellation policy.  Our fees are not covered by insurance.  Payment is due at the time of an appointment.  (See services and fees)

————–

RENEWALS:

1. If your condition has been stable since your last visit, and your certification expired less than six months ago, no new medical records are necessary. If your medication or treatment has changed, please bring a copy of  the progress note from your last visit with your PCP or specialist.

2. The last four digits of your social security number.

3. Picture Identification

Driver’s license   or  Picture ID with proof of residency   (e.g.: utility bill in your name).

 

4. A Patient Release Form must be completed and brought with you to the appointment. 

5. Please review our form entitled Medical Marijuana Benefits and Risks (PDF) before your appointment.

 

Please note our fees and cancellation policy.  Our fees are not covered by insurance.  Payment is due at the time of an appointment.  (See services)