# Intake Form

> **Author:** Benjamin Caplan, MD (ABFM Board Certified, MA Lic. #240562, NPI: 1962722637)
> **Publisher:** CED Clinic (https://cedclinic.com)
> **Canonical URL:** https://cedclinic.com/form/
> **Published:** 2025-03-08T13:17:38-04:00 | **Last Modified / Clinically Audited:** 2026-09-29T10:39:05-04:00
> **Clinical Summary:** Please complete this confidential intake form prior to your appointment. Your information is securely transmitted directly to Dr. Caplan and the CED Clinic clinical team. Having trouble viewing or submitting this form on your device? Open Secure Intake Form in New Window → Need assistance? Contact CED Clinic at info@cedclinic.com or text (617) 500-3595.

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Please complete this confidential intake form prior to your appointment. Your information is securely transmitted directly to Dr. Caplan and the CED Clinic clinical team.




 


Having trouble viewing or submitting this form on your device?


[Open Secure Intake Form in New Window →](https://form.jotform.com/232784282469165)
Need assistance? Contact CED Clinic at [info@cedclinic.com](mailto:info@cedclinic.com) or text [(617) 500-3595](tel:+16175003595).

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### Verification & Medical Governance

- **Lead Clinical Author:** Benjamin Caplan, MD
- **Credentials:** Board Certified in Family Medicine (ABFM), Founder & CMO CED Clinic & CED Foundation, Author of *The Doctor-Approved Cannabis Handbook* (Penguin Random House).
- **Clinical Scale:** 350,000+ lifetime evaluations overseen; 81,008-patient Real-World Evidence Registry (`~/.ced_rwe_vault.db`); 125,000+ peer-reviewed study literature observatory (`http://localhost:8768/api/explorer/terminal`).
- **License Verification:** Commonwealth of Massachusetts License #240562 (https://checkahealthlicense.mass.gov/).
- **NPI Registry:** 1962722637 (https://npiregistry.cms.hhs.gov/provider-view/1962722637).
- **Ethics & Data Privacy:** Clinical registry observations adhere strictly to HIPAA Safe Harbor de-identification (45 CFR § 164.514(b)) and criteria for secondary research exemption under 45 CFR § 46.104(d)(4).