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Noa Botanicals online patient intake form


Aloha!

First time patients who visit our dispensary will need to provide the information requested on this form. The form only needs to be completed once.

We suggest submitting the form in advance of your arrival to avoid any delays. The information you provide is validated confidentially with the Hawaii DOH Medical Cannabis Patient Registry. We will never share your private information.

Please fill in all information EXACTLY as it appears on your medical marijuana card.

After successful validation, you will receive a confirmation number by email or text. If the information you provided is incomplete, misspelled, or we are otherwise unable to validate the information, a Noa representative will contact you by email or text.

Please allow no less than 24 hours for us to process and validate your pre-registration. Please be sure to provide your confirmation number, which will be sent to you via email or text, at dispensary check-in.

Mahalo,
Noa Botanicals


STEP 1: MMJ REGISTRATION CARD INFORMATION
Please enter your mmj registration card information below. Be sure and type in the information EXACTLY as it appears on your 329 card.


REGISTRATION NUMBER
*
Enter the 10-digit registration number from your medical marijuana card.
This question is required
ISSUED:
*
Enter date issued
Month
Month
Day
Day
Year
Year
Please enter a valid date
EXPIRES:
*
Enter expiration date
Month
Month
Day
Day
Year
Year
Please enter a valid date
P: NAME AS IT APPEARS ON YOUR 329 CARD
*
[First] [MI] [Last}
This question is required
DOB:
*
Enter your date of birth
Month
Month
Day
Day
Year
Year
Please enter a valid date
PHYSICIAN:
*
Enter the name of physician or registered nurse EXACTLY as it appears on your 329 card
This question is required

STEP 2: BASIC INFORMATION​
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Home address
*
Please do not use hyphens in street address.
This question is required
MOBILE TELEPHONE NUMBER (including area code)
Your mobile is needed to text a confirmation number. We will never share your private information.

REGISTERED CAREGIVER (if applicable)
A registered caregiver is an individual selected by a patient and registered with the Department of Health to act as their agent in obtaining medication for them at the dispensary.
What is your registered caregiver's full name (if applicable)
Caregiver full name
What is your registered caregiver's phone number (if applicable)
Caregiver phone

The following two questions are optional but will help us in determining products to offer.

WHAT IS YOUR PREFERRED METHOD OF CONSUMING CANNABIS?
WHAT PRODUCTS ARE YOU INTERESTED IN PURCHASING?
What products would you like to see in our dispensary?


STEP 3: ACKNOWLEDGMENTS
Please read and respond to each acknowledgment below. (Required)
ALL QUESTIONS MUST BE ANSWERED YES IN ORDER TO PROCESS.
I attest that I will not engage in the diversion of cannabis. I understand that fraudulent distribution or resale of cannabis is a felony.
*
Please choose an answer
I understand that when under the influence of cannabis driving is prohibited and machinery should not be operated.
*
Please choose an answer
I understand cannabis, including medical cannabis produced by Noa Botanicals, should be kept away from children.
*
Please choose an answer
I acknowledge that Noa Botanicals does not provide medical advice.
*
Please choose an answer
I acknowledge that the law prohibits photography and video recording of any kind in the dispensary.
*
Please choose an answer
I acknowledge consumption of marijuana or marijuana manufactured products on the premises of the dispensary is prohibited.
*
Please choose an answer
I understand there may be health risks associated with using cannabis, including cannabis produced by Noa Botanicals.
*
Please choose an answer
I understand I may not distribute medical cannabis to any other individual.
*
Please choose an answer
I agree not to bring any weapons or anything that can be used as a weapon into Noa Botanicals facilities.
*
Please choose an answer
I understand that I must have a valid government-issued identification and a valid medical marijuana card during every visit to the Noa Botanicals dispensary.
*
Please choose an answer
I acknowledge that I may not purchase more than four ounces of marijuana in a fifteen-day period from any dispensary.
*
Please choose an answer
I agree at all times to abide by Hawaii law in regard to my use of medical cannabis and hereby release and waive all claims against Noa Botanicals from any and all liability related to my use of medical cannabis.
*
Please choose an answer
I have received the Noa Botanicals patient handbook, a copy of which can be found at noacares.com.
*
Please choose an answer
CERTIFICATION
I certify that the above is true and correct and agree to hold harmless and release Manoa Botanicals LLC dba Noa Botanicals (Noa), and its officers, managers, agents, and employees of any liability related to the use of medical cannabis purchased at the Noa Botanicals dispensary or sold by Noa Botanicals.
*
Please choose an answer
ELECTRONIC SIGNATURE
By signing this form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. I understand that signing this page constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.
Please sign below as your electronic signature using your mouse (computer) or finger (phone).
*
Full name here
Sign here
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