Patient Application

New Mexico Brief Relief protects your privacy by observing HIPAA regulations. New Mexico law ensures the “possession of, or application for, a Medical Cannabis permit shall not constitute probable cause or give rise to reasonable suspicion for any governmental agency to search the person or property of the person possessing or applying for the card”.

New Enroll Application

Please fill in the form below.





Phone CallTextEmail

Address

AlbuquerqueEspanola

History of Trauma, Pain or Medical Condition

Also select and describe a possible qualifying condition, don't worry if you don't see your diagnosis just select N/A


YesNo

YesNo


Please answer the following Questions

Please answer each question as if the symptoms were at there worst with out any type of cannabis to assist your symptom and/or any other type of treatment.

Repeated disturbing memories thoughts or images of a stressful experience from the past?


Repeated disturbing dreams of a stressful experience from the past?


Suddenly feeling as if a stressful experience were happening again (as if you were reliving it)?


Felling very upset when something reminded you of a stressful experience from the past?


Having physical reactions (example: heart pounding trouble breathing or sweating) when something reminded you of a stressful experience from the past?


Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?


Avoid activities or situations because they remind you of a stressful experience from the past?


Trouble remembering important parts of a stressful experience from the past?


Loss of interest in things that you used to enjoy?


Feeling distant or cut off from other people?


Feeling emotionally numb or being unable to have loving feelings for those close to you?


Feeling as if your future will somehow be cut short?


Trouble falling asleep or staying asleep?


Feeling irritable or having angry outbursts?


Having difficulty concentrating?


Being super alert watchful or on guard?


Feeling jumpy or easily startled?


Additional Licences Request

Please select if you would like to also apply for a personal productions license and/or select if you'd like sign up a care giver with you

YesNo

YesNo