Contact Us

330-212-5900
BotanicalMedConsultants@gmail.com

For general inquiries, please use this form. For a consultation, please complete the medical history form below.

Schedule a Consultation

Please complete and submit the following Medical History Form or download and print the form here to bring with you to your consultation.

Name

First Name

Last Name

Birthday

MM

DD

YYYY

Age

Email

Allergies (to medications)

Current Medications

Please list any current medications. If you are not on any medications, say "None"

Surgeries

Medical Diagnosis

Ever Seen a Pain Management Physician?

Yes

No

If yes, for what?

Pain Treatments, including Injections

What do you hope for with use of medical marijuana?

Additional Information