News and Best Practices

Should You Use a Patient Intake Form?

July 29, 2016

Does your dispensary use a patient intake form for all new customers? If not, maybe you should. Intake forms can be a powerful way to quickly learn about the patient so you can provide personalized service. They can also give you valuable information to help improve your business processes.

What should be included in a patient intake form? We’ve included an example form at the end of this article. Of course, it includes the patient’s name and contact information, but it also provides valuable information about the patient’s experience with cannabis and health issues relevant to cannabis users. It even gives you an opportunity to find out how they heard about you and gives them the chance to sign up for newsletters or other valuable patient information you provide. You’ll want to include verbiage assuring them of the information they are providing will be kept in confidence, and give them an opportunity to opt out of the form in favor of answering the questions directly to a budtender.

When to use a patient intake form

You’ll want to have all new patients complete a form on their first visit, and do it in the lobby area. You can then get the completed form to a budtender in advance of them meeting the patient. The budtender can take a minute to review the form and familiarize themselves with the customer’s background; this is a key to providing personal care.

Understanding a patient’s history with cannabis

Having up to date information about your patient’s cannabis usage, such as how much experience they’ve had and when, can help you match the type and dosage to their needs, and avoid adverse reactions to the medicine. If they haven’t used cannabis in many years, they may not understand that today’s product is much stronger than it was 20 years ago, strains are more unique and complex, and there are more options for ways to ingest it. Knowing about their experience can help your budtender educate and inform the patient, which is another important part of personalized care.

Below is a sample intake form. Feel free to use it, adapt it or even expand it if there are other items you would like to capture. Remember, it’s all about personalized care.


By Eric Stone
Dispensary Management Today articles are for informational purposes only and should not be considered legal guidance or advice on dispensary operations. You should contact an attorney or a qualified cannabis consultant for specific compliance and dispensary/retailing advice.


Example Patient Intake Form


[Your Logo Here]

This information will help recommend the most appropriate medicine for your unique needs.
All information will be held in strict confidence.


Patient Name___________________________________________________________________

Date__________________________ Phone Number____________________________________
How did you hear about us?



____Physician Referral

____Other (please specify)__________________________________________________


Is this your first time in a cannabis dispensary?

____ Yes             ____ No


Which best describes your level of cannabis use?

____First time user

____Sometime user

____Daily user

____Past user but not currently. How long has it been since you’ve used cannabis, and how heavily did you use it in the past? ________________________________________


What is your ingestion preference?






____Other (please specify)__________________________________________________

____Don’t have a preference


Would you like a private consultation with a medically knowledgeable budtender? (They are here to help you understand your medical options.)

____ Yes____ No____ Maybe another time


Are you prone to anxiety or any other form of chemical imbalance?

____ Yes____ No


If yes, please explain____________________________


Please tell us a little about your medical condition? (If you would prefer to do this face-to-face with your budtender leave blank.)





Please list any medications you are allergic to:_________________________________________



Have you ever had an adverse reaction to any medicine, including cannabis?

____ Yes____ No


If yes, please explain___________________________________


Would you like to be on our email list to receive newsletters, and information on new products, specials and cannabis use tips? Email address_________________________________________

Sign Up for Cannabis Cultivation Today

© 2019 CAN Performance Group, LLC. All rights reserved.