Secure patient form

Medical cannabis renewal intake

For patients Dr. Ewals certified before. Please complete this before your recertification visit.

We only need new records if your condition, diagnosis or treatment changed since your last visit. Ask the clinic that treats you to fax them to (701) 757‑0974.

Recertification is still a medical decision, and the state renews your card separately.

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

Required

About you

Your card

Which state do you live in? (required)

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

It's printed on your card and shown in your state portal account.

Has your address changed since your last visit? (required)

If so, bring a photo ID showing your new North Dakota or Minnesota address.

How it has been going

Have you had any of these side effects?

Changes since your last visit

Including over-the-counter medicines and supplements. Write None if nothing has changed.

Write None if nothing has changed.

Has your condition, diagnosis or treatment changed? (required)

New records go by fax to (701) 757‑0974.

Are you pregnant, breastfeeding or planning a pregnancy? (required)
Do you drive for work or work in a safety-sensitive job? (required)

Your questions

Before you send

Optional. Consent is not a condition of care.

Optional. Please don't email us medical records.

Sent privately to our care team

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