Secure patient form

Medical cannabis evaluation intake

Cannabis evaluation only. Not a testosterone or peptide visit. Please complete this before your evaluation so Dr. Ewals has time to prepare. Your answers go only to our care team.

Bring a photo ID with your North Dakota or Minnesota address. Records for the qualifying condition need to reach us before the visit: ask the clinic that treats you to fax them to (701) 757‑0974, or ask Will for another secure option. Please don't attach them here.

We do not bill insurance. An evaluation never guarantees certification: Dr. Ewals decides whether certification is appropriate, and the state makes the final decision on your card.

Have an emergency? Call 911 or go to the nearest emergency room.

Required

Visit type

Which state are you a resident of? (required)

We see North Dakota and Minnesota residents only. Moving here? Call Will at (218) 274‑4500.

Which visit is this? (required)

Certified by Dr. Ewals before? Use the renewal intake instead.

How will you be seen? (required)

Telehealth depends on your state and whether you're a new or returning patient. We'll tell you what applies.

Patient information

Your name as it appears on your photo ID.

Sex

Optional. Consent is not a condition of care.

As it appears on your photo ID.

We see North Dakota and Minnesota residents only.

The state's registration steps use email, so use one you check often.

Registry state (required)

The state whose medical cannabis registry you're applying to.

Bring the ID itself to your visit.

The front of your driver's license or state ID, as a photo or PDF, up to 15 MB. Or just bring it to your visit.

Optional.

Qualifying condition

North Dakota and Minnesota use different qualifying-condition lists. Use the diagnosis name from your records. One condition is enough.

Not sure it qualifies? Call Will at (218) 274‑4500 before your visit.

Symptom severity today (required)

0 = none, 10 = worst imaginable.

Treatments already tried

Which treatments have you tried?

Cannabis use and safety screening

Used cannabis before? (required)
Which forms?
Did it help?
Bad reaction (panic, psychosis, severe vomiting)? (required)
Ever diagnosed with schizophrenia or schizoaffective disorder? (required)
Pregnant, breastfeeding, or trying to conceive? (required)

Medical history

Please check any that apply to you.

Medications and allergies

Are you currently taking any prescribed medications? (required)

Add any over-the-counter medicines and supplements too. Include any CBD or cannabis products.

Do you have any drug allergies? (required)

Acknowledgments

Signature

Typing your full legal name here is your electronic signature.

Leave blank if you are the patient.

Sent privately to our care team

Your information is kept private and used only to contact you about your care.