New Patient Request

CANNABIS CERTIFICATION REQUEST FORM
for Maryland Residents Only.

* Indicates required field

Legal Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Gender *

Date of Birth (mm/dd/yyyy) *

Email *

Cell Phone Number *

It ok to send me text/email reminders of appointments, cancellations and/or paperwork that is due. *

Yes

MMCC Issued ID Number *

If you do not have a MMCC Issued ID number, please click the link below to register with The State of Maryland
cannabis.maryland.gov/pages/patients_regisadult.aspx

Please briefly explain why you are seeking a medical marijuana card *

I understand that no insurance company will pay for the medical cannabis card certification or for any related cannabis products. *

Yes

INITIAL CERTIFICATION: $100
ANNUAL RECERTIFICATION: $50

Once you have submitted this form, you will be redirected to schedule your appointment.

*This information will be sent to a non-HIPAA compliant email. Please note this is not a secure means of communication so your confidentially cannot be ensured.

Submit

CANNABIS CERTIFICATION REQUEST FORMfor Maryland Residents Only.

Once you have submitted this form, you will be redirected to schedule your appointment.

CANNABIS CERTIFICATION REQUEST FORM
for Maryland Residents Only.