New Patient Request

CANNABIS CERTIFICATION REQUEST FORM

* 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 *

Is it ok to send you text reminders of appointments, cancellations and/or paperwork that is due? *

Yes No

MMCC Issued ID Number (if applicable) *

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

After you have been approved for services, you will receive an email with a link to the Simple Practice Healthcare Portal and instructions with how to schedule your first 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