Patient Form
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UPLOAD MEDICAL RECORDS
ATTENTION! YOU MUST UPLOAD AN IMAGE OF YOUR MOST RECENT MEDICAL MARIJUANA DOCUMENT. This document can be provided as a letter, certificate or plastic card. FAILURE TO COMPLY WILL RESULT IN APPLICATION REJECTION! The recommendation certificate or card must be easy to read. The date must indicate that it will expire soon or has already expired within the past 6 (six) months.
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DISCLAIMERS
ATTESTATION
RELEASE OF LIABILITY
DISQUALIFIERS
DIGITAL SIGNATURE
By electronically signing this document, you declare under penalty of perjury that the information on this form is true and correct.
Additionally, you are also aware that your recommendation may be revoked at any time if you have perjured or misrepresented yourself on this form.
Note: Filling out this questionnaire does not guarantee a medical marijuana recommendation.
Please sign below using a stylus, your mouse, or your finger and then click “SUBMIT”