SHAGGY'S BAGGY VIRTUAL KIOSK Beach Health Center Patient Intake Form
Your personal data privacy is protected through our system, we are compliant with HIPAA. - You must be 18 years old or older with a VALID MAINE STATE LICENSE OR ID. - Virtual applications are processed Monday - Friday 10am - 6pm, Saturdays Noon - 6pm. - We are Closed Sundays - You will get a TEXT with a digital medical card within 2 hours (Monday - Friday), if the form is COMPLETED OUTSIDE THE HOURS it will process in the order received during normal hours the next day. - Applications submitted 6pm or after on Saturdays and anytime Sundays will be processed the following Monday -Virtual applications are $25 no tax SPONSORED BY SHAGGY'S BAGGY
Patient Name
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First Name
Last Name
Patient Birth Date MM/DD/YYYY
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Please select a month
January
February
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Please select a day
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Please select a year
2026
2025
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Year
DATE OF BIRTH MM/DD/YYYY
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Phone Number- CHECK THIS NUMBER! WE WILL TEXT YOUR DIGITAL MED CARD TO THIS NUMBER WITHIN 2 HOURS BE SURE IT IS CORRECT. PLEASE INCLUDE YOUR AREA CODE
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YOUR CELL NUMBER
Address - WHERE WE ARE TO MAIL THE MEDICAL CARD - if you do not want a physical card mailed, and only want the digital card that is texted to you, check the box a the bottom of the application. you still have to fill in this portion either way
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient E-Mail - IF YOU DO NOT HAVE AN EMAIL USE NONE@NOEMAIL.COM
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Patient Medical History
OPTIONAL
Do you have any of the following conditions/symptoms? (Please check all that apply) - OPTIONAL
Anxiety Disorder
Muscle cramps
Nausea
Anorexia
Pain
PTSD
Cron's Disease
Fibromyalgia
Insomnia - SLEEPLESSNESS
Headaches
Cancer
Seizures
Multiple Sclerosis
DEPRESSION
ARTHRITIS
GLAUCOMA
Other
Please attach your VALID Maine State ID / Driver's License (we can accept paper Maine state license that are still valid with a clear issue and expiration date)
*
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WE CANNOT ACCEPT PASSPORTS, PASSPORT CARDS, MAIL, REGISTRATIONS, INSURANCE, OUT OF STATE LICENSE OR ANYTHING OTHER THAN THE MAINE STATE LICENSE OR ID. ONLY MAINE STATE LICENSE OR ID IS ACCEPTABLE FOR A MEDICAL CARD IN MAINE. PASSPORTS AND PASSPORT CARDS ARE FEDERAL IDENTIFICATION, CANNABIS IS FEDERALLY ILLEGAL. MAINE MEDICAL PROGRAM IS A STATE PROGRAM AND AS SUCH ONLY A VALID MAINE STATE LICENSE OR ID IS ACCEPTED. IF YOU DO NOT HAVE THAT DO NOT GO ANY FURTHER ON THIS FORM. IF YOU UPLOAD ANYTHING OTHER THAN A VALID MAINE STATE LICENSE OR ID YOU WILL FORFIT THE $1.03 SQUARE PROCESSING FEE AND IT CAN TAKE 7-10 DAYS TO GET THE MONEY BACK IN YOUR ACCOUNT. IF YOU ARE UNSURE ABOUT WHAT YOU ARE ABOUT TO UPLOAD TEXT US AT 207-229-4492 AND ASK US.
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Patient Agreement & Consent
* Please sign below that you have read, understood, and answered the above questions truthfully to the best of your knowledge. Please be advised that payment for all services will be due at the time services are rendered unless prior arrangements have been made.
Please read and check each item:
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I hereby declare that I have truthfully and completely disclosed all information regarding my medical and behavioral health conditions.
I understand that Beach Health Center will not send my medical information or card status to anyone unless I send a written request to do so
The Maine Medical CANNABIS Program is protected by the medical privacy act. I understand that no one knows I have a MMCP card unless I tell them or show them my card. I understand that there is no registry in Maine.
I attest that I have attached a valid Maine state license or ID that is in my possession and is not revoked, surrendered, or lost.
I understand that applications are processed Monday - Friday 10am - 6pm, Saturdays Noon - 6pm, with in 2 hours. Submissions after 6pm will be processed the next business day, anything after 6pm on Saturday or anytime Sunday will be processed Monday.
I understand the physical medical card will be mailed to me, there is no pick up available, YOU HAVE AN OPTION BELOW THE PAYMENT FEILD TO NOT HAVE A PHYSICAL CARD MAILED AND ONLY RECIVE THE DIGITAL CARD
BEACH HEALTH CENTER WILL TEXT YOU THE DIGITAL MED CARD, IT WILL NOT BE COMING FROM SHAGGY'S BAGGY, IT WILL BE COMING FROM THE MEDICAL PROVIDER
Patient Signature
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Today's Date
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Month
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Day
Year
Date
How would you like to be notified next year that your renewal is coming due?
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email
mail
none
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SHAGGY'S BAGGY Virtual Maine Medical Cannabis Certificate
$25.00
$
25.00
MMCP virtual med card certificates offered for $25. NO TAX Must be 18+. Must have a Maine state license or identification card . No medical documentation needed. Sarah Weinstein of Beach Health Center is the Nurse Practitioner for certification. SPONSORED BY SHAGGY'S BAGGY
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DO YOU WANT THE PHYSICAL MED CARD MAILED TO YOU? YOU WILL GET THE DIGITAL CARD TEXTED AS WELL AS A SHAGGY'S BAGGY COUPON. THIS IS JUST A QUESTION ABOUT THE PHYSICAL CARD
*
Please Select
MAIL THE PHYSICAL CARD TO ME
DO NOT MAIL THE PHYSICAL CARD, I ONLY WANT THE DIGITAL CARD THAT IS TEXTED TO ME
Please choose one:
*
THIS IS MY 1ST MED CARD (IN MAINE)
I'VE HAD A MED CARD BEFORE (IN MAINE)
I'VE HAD MED CARDS SINCE THE PROGRAM BEGAN (IN MAINE)
CLOSED EARLY SATURDAY 10.4.25 AT 5:30PM
SUBMISSIONS 5:30 OR AFTER WILL BE PROCESSED BETWEEN NOON - 3 PM SUNDAY 10.5.25
5.30.26 THE MAINE.GOV PROVIDER PORTAL, THAT WE CREATE MED CARDS THOUGH, IS DOWN AND HAS BEEN DOWN SINCE 1.15PM. WE WILL GET THE CARD CREATED AS SOON AS POSSIBLE, BUT THAT MAY BE MONDAY AS THERE IS NO TECH SUPPORT ON WEEKENDS
VACATION NOTICE:
THIS PORTAL WILL BE CLOSED, AND BE INACCESSIBLE, FROM 6PM THURSDAY 3.26.26 UNTIL 10AM TUESDAY 4.7.26
420 IS COMING! PLEASE BE PATIENT DELAYS EXPECTED. ANYTHING SUBMITTED BEFORE 6PM ON 4/20/26 WILL BE PROCESSED THE SAME DAY.
SUBMIT
KNOWN DELAYS. BELOW ARE THE DAYS/TIMES THAT WE KNOW THERE ARE DELAYS PROCESSING APPLICATIONS (DUE TO TRAVEL AND SET UP FOR IN PERSON LOCATIONS):
MONDAYS 3PM - 4PM, TUESDAYS 11AM - NOON, WEDNESDAYS 2PM - 3PM, THURSDAYS 11AM - NOON, FRIDAYS 11AM - NOON AND 3PM - 4PM. SATURDAYS START AT NOON, CLOSED SUNDAYS
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