OMMP Appointments

Full Name

Phone

Email Address

Preferred Method of Contact Preferred Method of Contact Phone Email

May we leave a detailed message/response? May we leave a detailed message/response? Yes No

Will you be adding a caregiver to your application? Will you be adding a caregiver to your application? Yes No

Do you have a grower? Do you have a grower? Yes No

Are you 18 or older? Are you 18 or older? Yes No

Do you have a drug related felony? Do you have a drug related felony? Yes No

Do you have valid ID? Do you have valid ID? Yes No

When were you last seen by a doctor for your qualifying condition? When were you last seen by a doctor for your qualifying condition? 0-6 Months 6-12 Months 12-18 Months 18-24 Months 24-36 Months

Have you ever been an OMMP patient at any point in your life? Have you ever been an OMMP patient at any point in your life? Yes No

Are you an existing patient with 1st Step Clinic? Are you an existing patient with 1st Step Clinic? Yes (Renewal) No (New Patient)

Would you like the New Patient Paperwork sent via email? Would you like the New Patient Paperwork sent via email? Yes, please use email listed above I'll schedule to come to the clinic for paperwork

Qualifying Medical Conditions Qualifying Medical Conditions Cancer Nausea Migraines Alzheimer's HIV - AIDS Severe Pain Muscle Spasms Cachexia Fibromyalgia Disc Disease PTSD Seizures Glaucoma Multiple Sclerosis Other

Other Conditions