NM MMJ Intake Form — Configuration Guide

Partner: Crush Wellness  |  State: New Mexico  |  Based on: General Intake Form (Form #8)  |  v1.0 · April 2026

EXISTS Already in general form — keep as-is UPDATE LABEL Exists but reword for NM ADD NEW Does not exist — create fresh NM STATE BLOCK Add with State of evaluation = NM CONSENT Add/replace consent section

Before you start — Setup Steps

1
Duplicate the General Intake Form (Form #8). Rename it: "New Mexico Medical Cannabis Intake Form — Crush Wellness"
2
The fields marked EXISTS are already in the duplicated form. You only need to configure the ADD NEW and NM STATE BLOCK items.
3
For all NM STATE BLOCK fields: check "Show this question by condition from patient profile" and set State of evaluation = NM
4
Replace the default Consent with the NM Patient Agreement text provided at the bottom of this document.
SECTION A — Personal Information (top of form)
# Field Label (exact) Field Type Attribute Name Options / Settings Action
— Section header text block Text block — Text to display:
"Please enter your information (MUST MATCH NEW MEXICO STATE ID):"		 ADD NEW
Add a text block at the top of the personal info section
1a First name Text field first_name Load from patient profile: ✓
Required: Yes		 EXISTS
1b Middle name Text field middle_name Load from patient profile: ✓
Required: No		 EXISTS
1c Last name Text field last_name Load from patient profile: ✓
Required: Yes		 EXISTS
1d Date of Birth Date field birthdate Format: MM/DD/YYYY
Required: Yes		 EXISTS
1e Sex assigned at birth Radio / Dropdown sex_assigned_at_birth Male Female Intersex Required: Yes ADD NEW
1f Gender Identification Dropdown gender_identification Male Female Non-binary Genderqueer Transgender Prefer not to say Other Required: Yes ADD NEW
1g Weight Text field weight Placeholder: "Weight (lbs)"
Required: Yes		 EXISTS
1h Height Text field height Placeholder: e.g., 5'10"
Required: Yes		 EXISTS
1i–1l Address, apartment, city, state, zip Address block address Enable all sub-fields: Apartment ✓, City ✓, State ✓, Zip code ✓
Load from patient profile: ✓
Required: Yes		 EXISTS
1m County Dropdown county_of_residence Helper text: "Required for state registration"
All 33 NM counties:
Bernalillo, Catron, Chaves, Cibola, Colfax, Curry, De Baca, Doña Ana, Eddy, Grant, Guadalupe, Harding, Hidalgo, Lea, Lincoln, Los Alamos, Luna, McKinley, Mora, Otero, Quay, Rio Arriba, Roosevelt, Sandoval, San Juan, San Miguel, Santa Fe, Sierra, Socorro, Taos, Torrance, Union, Valencia
Required: Yes
State of evaluation = NM 		NM STATE BLOCK
Same pattern as FL county field
1n Phone number Phone field phone Load from patient profile: ✓
Required: Yes		 EXISTS
1o Alternative phone number Phone field alternative_phone Load from patient profile: ✓
Required: No		 EXISTS
1p Email Email field email Load from patient profile: ✓
Required: Yes		 EXISTS
1q State-issued ID Number Text field state_issued_id_number Placeholder: "State-issued ID number"
Required: Yes
State of evaluation = NM		 NM STATE BLOCK
SECTION B — ID Verification & Patient Type
# Field Label (exact) Field Type Attribute Name Options / Settings Action
2 Is the address on your state-issued Photo ID/Driver's License the same as the address you entered on the previous screen? To avoid delays in processing, it is best that your ID matches your address. Yes / No id_address_match 1. Yes 2. No → show warning text: "To avoid delays, your ID address should match. Consider updating your ID or using your ID address." Required: Yes
State of evaluation = NM 		NM STATE BLOCK
3 Are you a NEW Patient or RECERTIFICATION Patient? (You are a new patient if you have never been seen through the Crush Wellness Portal) Yes / No patient_type_nm 1. New Patient 2. Recertification Patient → show Q4 below Required: Yes
State of evaluation = NM 		NM STATE BLOCK
4 For MEDICAL CANNABIS RENEWALS ONLY: Enter the Barcode / ID Code (the number from the current New Mexico medical cannabis card) Short answer nm_renewal_card_barcode Placeholder: "Enter barcode / card ID number"
Conditional: show only if Q3 = Recertification Patient
Required when visible: Yes
State of evaluation = NM 		NM STATE BLOCK
Same pattern as MD card number field
SECTION C — Consent & Acknowledgments
# Field Label (exact) Field Type Attribute Name Options / Settings Action
5 Are you completing this form for yourself or on behalf of someone else? Yes / No + sub-field completing_for_other 1. For myself 2. I am completing this form on behalf of someone else (parent, guardian, or through Power of Attorney) Always show consent checkbox below (not conditional):
"I agree and consent for treatment, diagnostic, evaluation, and medical services from medical practitioners referred through Crush Wellness. I understand that treatment may be via audio-video telemedicine."
Checkbox label: "I Agree" — Required: Yes 		ADD NEW
Similar to "Are you filling this out for a minor?" pattern
6 I acknowledge that in order to maintain my scheduled appointment date and time, it is necessary for me to fully complete this form and submit it. Checkbox ack_complete_form Checkbox label = full statement above
Required: Yes		 ADD NEW
7 I understand that Crush Wellness and their providers cannot be held responsible or expected to participate in any kind of legal or employment-related matters that a patient is involved in, including but not limited to: Child Protective Services, Department of Motor Vehicles, government agencies, parole, and probation. If you have any questions, please contact us prior to your appointment. Checkbox ack_legal_disclaimer Checkbox label = full statement above
Required: Yes		 ADD NEW
8 I understand that the charges for booking an appointment will appear as: MEDVISIT and I authorize the transaction. I understand that I will be eligible for a refund only if I am denied by the provider. Checkbox ack_billing Checkbox label = full statement above
Required: Yes		 ADD NEW
9 I am responsible for maintaining a stable internet or phone connection for the telemedicine video call during my appointment. I understand that I will not receive a refund for any issues arising from a poor internet connection on my end or a no show/missed appointment. Checkbox ack_internet Checkbox label = full statement above
Required: Yes		 ADD NEW
SECTION D — Medical History
# Field Label (exact) Field Type Attribute Name Options / Settings Action
10 Are you currently breastfeeding? Yes / No breastfeeding 1. Yes2. NoRequired: Yes ADD NEW
11 Are you currently pregnant or planning on getting pregnant? Yes / No pregnant_or_planning 1. Yes2. NoRequired: Yes ADD NEW
12 What current medical conditions or complaints are you seeking alternative medicine for? Please check all that apply with explanation if possible: Multi-select checkboxes primary_conditions At least 1 required.
NM qualifying conditions (exact):
Alzheimer's Disease · Amyotrophic Lateral Sclerosis (ALS) · Anxiety · Autism Spectrum Disorder · Cancer · Crohn's Disease · Damage to the Nervous Tissue of the Spinal Cord (with objective neurological indication of intractable spasticity) · Epilepsy/Seizure Disorder · Friedreich's Ataxia · Glaucoma · Hepatitis C Infection currently receiving antiviral therapy · HIV/AIDS · Hospice Care · Huntington's Disease · Inclusion Body Myositis · Inflammatory Autoimmune-mediated Arthritis · Insomnia · Intractable Nausea/Vomiting · Lewy Body Disease · Multiple Sclerosis · Obstructive Sleep Apnea · Opioid Use Disorder · Painful Peripheral Neuropathy · Parkinson's Disease · Post-Traumatic Stress Disorder · Severe Anorexia/Cachexia · Severe Chronic Pain · Spasmodic Torticollis (Cervical Dystonia) · Spinal Muscular Atrophy · Ulcerative Colitis
State of evaluation = NM 		NM STATE BLOCK
Same pattern as MA, CO, WA condition blocks
13 Please list any other past medical history not mentioned above, such as: High blood pressure, Diabetes, etc. (If none, write N/A) Long answer other_medical_history Placeholder: "If none, write N/A"
Required: Yes		 ADD NEW
14 Are you currently taking any medications on a regular chronic basis? (Prescription medicine, Over-the-counter (OTC) medication, Herbal medication, Vitamins and Minerals) Yes / No + sub-field current_medications 1. Yes → show sub-field: "Please list your current medications" (Long answer, required) 2. No Required: Yes ADD NEW
15 Do you currently use (smoke/chew) tobacco? (Yes/No). If yes, how often? (Cigarettes per day; Quantity of chew per day) If you used to smoke, how long ago was your last use of nicotine? Yes / No + sub-fields do_you_smoke_tobacco 1. Yes → show 2 sub-fields:
  • "How often? (e.g., cigarettes per day / chew per day)" — Long answer
  • "If former user, how long ago was your last use of nicotine?" — Short answer 2. No Required: Yes 		UPDATE LABEL
Field exists (do_you_smoke_tobacco). Update the label to match NM wording exactly.
16 Do you currently drink alcohol? (Yes/No). If yes, how often? (# drinks per week) Yes / No + sub-field do_you_drink_alcohol 1. Yes → show sub-field: "How many drinks per week?" — Short answer 2. No Required: Yes EXISTS
Verify label matches exactly
17 Do you currently use marijuana? (Yes/No). If yes, how often? Yes / No + sub-field do_you_use_marijuana 1. Yes → show sub-field: "How often?" — Short answer 2. No Required: Yes EXISTS
Verify label matches exactly
18 Do you have any allergies to medication? (Yes/No). If yes, list medicines Yes / No + sub-field medication_allergies 1. Yes → show sub-field: "Please list the medicines you are allergic to" — Long answer 2. No Required: Yes EXISTS
Verify label matches exactly
19 Have you ever been hospitalized? (Yes/No). If yes, please provide dates and details. Yes / No + sub-field hospitalized 1. Yes → show sub-field: "Please provide dates and details" — Long answer 2. No Required: Yes EXISTS
20 Have you ever had surgery? (Yes/No). If yes, please provide dates and details. Yes / No + sub-field had_surgery 1. Yes → show sub-field: "Please provide dates and details" — Long answer 2. No Required: Yes EXISTS
21 Any form of regular exercise? (Yes/No) If yes: What type of exercise, # of times per week Yes / No + sub-fields do_you_exercise 1. Yes → show 2 sub-fields:
  • "What type of exercise do you do?" — Short answer
  • "How often?" — Short answer (attribute: how_often_do_you_exercise) 2. No Required: Yes 		EXISTS
SECTION E — File Uploads
# Field Label (exact) Field Type Attribute Name Options / Settings Action
22 REQUIRED: Please upload a copy of your NM STATE-ISSUED Photo ID, which lists the address that was used earlier in the form. Driver's License is preferred. Your ID is used by the state to confirm your resident status, so it MUST match the state where you are applying. (NOTE: Passport and Passport cards are not acceptable, as they do not show the address) NOTE: Maximum file size: 25Mb File upload nm_state_id_upload Accepted: JPG, PNG, PDF
Max size: 25 MB
Required: Yes
State of evaluation = NM 		NM STATE BLOCK
23 This is not a requirement, but please upload proof of your existing medical condition, if possible. Examples of acceptable proof: Medical records, Doctor's notes, Visit summary from your doctor, Letter from therapist or chiropractor, Prescription with diagnosis, etc. PROVIDED DOCUMENTATION MUST BE SPECIFIC TO YOUR QUALIFYING DIAGNOSIS. NOTE: Maximum file size: 25Mb File upload medical_condition_proof_upload Accepted: JPG, PNG, PDF
Max size: 25 MB
Required: No (optional) 		ADD NEW
SECTION F — Patient Agreement (Q24) — Replace default consent with NM version

Consent field label: "Medical Marijuana Patient Agreement"  |  Checkbox label: "Yes, I have read and agree to the Medical Marijuana Patient Agreement"  |  Required: Yes

Full text to paste into the consent scroll box (verbatim):

I understand that by selecting YES, I acknowledge my comprehension and agreement with the following information concerning Medical Marijuana ("Medical Cannabis"). If I have any questions or do not understand the details provided below, I will not sign this agreement or utilize Medical Marijuana.

Acknowledgments of Disclosure and Informed Consent

I understand that the evaluation for a physician's recommendation for Medical Marijuana is based, in part, on the medical information I have provided. I affirm that I have provided accurate information about my medical condition and my intention is to use Medical Marijuana solely as necessary for treating my medical condition.

I understand that potential side effects of Medical Marijuana include, but are not limited to: abnormal sleep, agitation, anxiety, bronchitis, confusion, cough, depression, dependency, dizziness, drowsiness, dry mouth, fatigue, feelings of euphoria, headache, hunger, impaired motor skills, impaired vision, irregular heartbeat, laryngitis, loss of appetite, low blood pressure, memory loss, nausea, nervousness, numbness, paranoia, poor physical condition, psychotic symptoms, sedation, shortness of breath, slower reaction time/inability to concentrate, suppression of the immune system, vomiting.

I understand that Cannabis can have intoxicating effects, has not undergone analysis or approval by the United States Food and Drug Administration (FDA), and has been produced without FDA oversight for health, safety, or efficacy. Cannabis may contain unknown quantities of active ingredients, impurities, or contaminants.

I understand that there is a potential risk of dependency on Cannabis, and I may experience withdrawal symptoms upon discontinuation of its use.

I understand that my tolerance to Cannabis may increase over time, necessitating higher doses for the same symptom relief.

I understand that Cannabis may worsen symptoms of schizophrenia or bipolar disorder in individuals predisposed to those conditions.

I understand that women should avoid consuming Cannabis products while planning to become pregnant, during pregnancy, and while breastfeeding.

I understand that combining the use of Cannabis with alcohol is not recommended and may lead to unexpected and hazardous side effects.

I understand that having a medical marijuana recommendation does not provide legal protection regarding the cultivation and/or processing of marijuana.

I understand that the effectiveness and potency of Cannabis may vary significantly depending on the strain and method of ingestion.

I understand that the intoxicating effects of Cannabis consumed orally or ingested may be delayed by two or three hours or more.

I understand that the use of Cannabis may affect coordination, cognition, and judgment. While under the influence of Cannabis, I will not drive, operate machinery, or engage in potentially hazardous activities.