Intro Schedule Demo Extremely Flexible MMJ Patient Intake
Form Builder is 100% Customizable
Free Trial Form Builder

Easily Create Custom Patient Intake Forms For Medical Marijuana Patients

Show and hide sections, add your own questions, add custom disclaimers, add fields for uploading medical records and more

Form Shows Qualifying Medical Marijuana Conditions For Your State Automatically

Show or hide any combination of 4 upload options for the patient’s medical records, ID, photo and proof of residency. You can set the fields as either required or not required and add custom text to the upload option

Add Your Own Custom Questions, Drag & Drop Questions For Order

What Kind of Questions Can Be Added?

  • Text: Single row input field for entering text
  • Text Area: Multiple row input field for entering text
  • Radio Buttons: Fields that allow only one option to be selected
  • Check Boxes: Fields that allow one or more options to be selected
  • Drop Down Menu: Drop down menu that will allow only one option to be selected

Add Custom Upload Options for Photo, ID, Medical Records & Proof of Residency

Show or hide any combination of 4 upload options for the patient’s medical records, ID, photo and proof of residency. You can set the fields as either required or not required and add custom text to the upload option

Show & Hide Pre-Built Sections For Medical + Social Questions

Pre-Built Form Sections Include

  • Medical History
  • Medical Questions
  • Female Questions
  • Social Questions

Add Custom Disclaimers That  Create Unique E-signed PDF’s

Add Payments to Your Custom Form

Combine Form With Telehealth & Appointment Web Widgets

Forms Automatically Create a PDF & Add it to the Patient’s EMR

See How Verify MC Can Help Your Medical Marijuana Clinic

Schedule Demo