Registered Agent/Parent/Guardian Form

Medical Marijuana Cards logo_edited_edit

Please answer all questions and hit SUBMIT at the bottom. This information is kept completely private.

This section is for information about the PATIENT

First Name of the PATIENT*

Middle Name (or initial) of the PATIENT - if it's on their ID

Last Name of the PATIENT*

Email of the PATIENT*

This section is for information about the Registered Agent, Parent, or Legal Guardian

Who are we adding to the Medical Card?

Registered Agent

Parent

Legal Guardian

First Name of the person to add*

Middle Name (or initial) - if it's on their ID

Last Name of the person to add*

The person's Date of Birth

Scroll to find year and select the year, then use arrow to select month, then the day

The person's email

The person's Mailing Address

The state allows you to list two Parents or Guardians, if you want

I have a second Parent/Guardian to add

First Name of the second person to add

Middle Name (or initial) - if it's on their ID

Last Name of the second person to add

The second person's Date of Birth

Scroll to find year and select the year, then use arrow to select month, then the day

The second person's Email

The second person's Mailing Address

If you already have your medical card, you can pick whether we meet by video or just a phone call.

I'd like a video call

I'd like a phone call.

For video calls I prefer to use

Please type your name below and hit submit. This will serve as a digital signature confirming you are either the patient or have authorization to request this on the patient's behalf.

Hit this button to submit the form

PLEASE NOTE: Filling out this form is not the same as making an appointment. If you haven't made an appointment yet, please be sure to do that after you successfully submit the form. You can do that on the Services page or click here (don't worry, clicking this will open a new window).

After you hit Submit, you should either be taken back to a box above that is missing required information or be redirected to a Thank You page. You will also get an email thanking you for submitting the form. If you are unsure whether or not the form was successfully submitted, wait a few minutes and check all of your email (including spam) for the "thank you" email.