CareTrax Forms

Quick Reg -Lake Worth

Used by Staff to create Patient Record from walk-ins or patients calling by phone.

Patient Information
Name
N/A

Required First Required Last
Email *
N/A
Mobile Phone *
N/A

### ### ####
Address
N/A

Street Address City
County (not Country) State
Zip Code
How did you find out about Liberate? *
N/A

Friend/Friend
Liberate Employee
Drive by
Google/Internet
Walk-in
Other
Who referred you?
N/A

First Last
Date of Birth *
N/A

MM/dd/yyyy
Sex *
N/A

-Select-
S.S.N. *
N/A
Referring Doctor
N/A

Please note the physician who has your existing medical records.
Reason for seeking treatment *
N/A

Why are you are seeking a recommendation to use medical marijuana and/or see our physician for a consultation.
Do you take any of the following medications?
N/A
Tobacco and Alcohol Usage
N/A

Indicate whether you use tobacco and/or currently drink alcohol.
Do you have any of the following qualifying conditions? *
N/A
Do you have any of these conditions?
N/A
Do you have electronic copies of your medical records to upload? *
N/A

Yes
No
Upload Medical Records and Drivers License (for proof of residency)
N/A
Upload file
You can upload up to 3 files here, each with a 20MB size limit per file.
Indicate your consent to release your medical records: *
N/A

-Select-
Contact Type *
N/A

Patient
Liberate Office *
N/A

Lake Worth
Contact Status *
N/A

Contacted