Medical Marijuana Qualifications - Accudoc Urgent Care

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Batesville: 812.932.3224 | Greensburg: 812.662.9500 | Harrison: 513.845.4558

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Do you qualify for medical marijuana?

Name

Page 1 of 4

Have you been diagnosed with any of the following 21 qualifying conditions? *

Acquired immune deficiency syndrome

Alzheimer's disease

Amyotrophic lateral sclerosis

Cancer

Chronic traumatic encephalopathy

Crohn's disease

Epilepsy or another seizure disorder

Fibromyalgia

Glaucoma

Hepatitis C

Inflammatory bowel disease

Multiple sclerosis

Pain that is either of the following: Chronic and severe; Intractable

Parkinson's disease

Positive status for HIV

Post-traumatic stress disorder

Sickle cell anemia

Spinal cord disease or injury

Tourette's syndrome

Traumatic brain injury

Ulcerative colitis

No, I have not received a diagnosis of any of the conditions listed above

Page 2 of 4

Are you an Ohio resident? *

Yes

Do you have an Ohio driver's license? *

Yes

Page 3 of 4

Is this recommendation for you? *

Yes

Are you the caretaker of someone who needs a recommendation? *

Yes

Page 4 of 4

Are you a veteran? *

Yes

Batesville, IN

20 Alpine Drive
Batesville, IN 47006
Phone: 812.932.3224
Fax: 812.932.3229

Greensburg, IN

2311 N St Rd 3
Greensburg, IN 47240
Phone: 812.662.9500
Fax: 812.663.6102

Harrison, OH

620 Ring Road, Suite B
Harrison, OH 45030
Phone: 513.845.4558
Fax: 513.845.4568

Do you qualify for medical marijuana?

Batesville, IN

Greensburg, IN

Harrison, OH

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