Missouri Telehealth Appointment


Provide a basic medical history and book an appointment with a licensed doctor. The $135 fee includes your
consultation fee and approval recommendation.

Your Information

Demographic Information

(max file size 50 MB)

General Information

Medical Information

What is the main problem for which you seek evaluation and treatment today (i.e. nausea, anorexia, spasms, pain, etc.)?

List all of your current prescription medications. List the names, dosage, frequency of use, and how long taken of each.

List products that you use or have used in the past for the condition for which cannabis is used (intended), i.e. ibuprofen, aspirin, glucosamine, milk thistle, etc.

Do you or have you used nicotine, alcohol, or caffeine? If so list the frequency of use, years of use, and a quit day if applicable.

Female Reproductive History (Leave section blank if it does not apply to you)