Registered Agent/Parent/Guardian Form | Athena Heals Medical Marijuana Cards

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Formulario de admisión del paciente

Responda todas las preguntas y presione ENVIAR en la parte inferior. Esta información se mantiene completamente privada.

This section is for information about the PATIENT

Nombre (como aparece en la identificación)

Segundo nombre/inicial (solo si está en la identificación)

Apellido (como aparece en la identificación)

Correo electrónico

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 required

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

The person's email

Dirección de envio

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.

Aplicación de video preferida si no es zoom

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

Después de enviar, debe ser redirigido a un cuadro de arriba en el que falta la información requerida o ser redirigido a una página de agradecimiento. También recibirá un correo electrónico agradeciéndole el envío del formulario. Si no está seguro de si el formulario se envió con éxito o no, espere unos minutos y verifique todo su correo electrónico (incluido el correo no deseado) en busca del correo electrónico de agradecimiento.

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.