Patient Form
First Name
Middle Name
Last Name
Gender
Drivers Lic. or State ID
Email
Phone
Contact Me By
Date Of Birth
How Did You Hear About Us?
DISCLAIMERS
REQUIREMENTS FOR DISQUALIFICATION
ATTESTATION
RELEASE OF LIABILITY
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”