Firearm Medical Clearance Form
Complete this form to provide necessary information for medical clearance related to firearm access or use.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Medical Clearance Request
*
Relevant Medical History (e.g., neurological or physical conditions affecting safety)
*
Current Medications (list all prescribed and over-the-counter medications)
*
Mental Health History Relevant to Firearm Safety
*
No relevant history
History of depression
History of anxiety or panic disorders
History of psychosis or bipolar disorder
Other (please specify)
Substance Use History (past or present)
*
No history of substance use
Current use (alcohol, drugs, or other substances)
Past use, not current
Other (please specify)
Recent Episodes Affecting Judgment or Safety (within the past year)
*
No recent episodes
Recent hospitalization for mental health
Recent substance-related incident
Other event affecting judgment/safety
Submit Medical Clearance
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