Agreement
By clicking the checkbox below, I agree to truthfully and completely disclose information regarding my medical conditions and to provide supporting documents if needed, as well as agree to receive text messages to the phone number provided through this form.
I consent to an evaluation by the Physician/Nurse Practitioner to be certified for the medical use of cannabis.
I have read the
Notice of Privacy Practices and accept them.
Participation in a Medical Marijuana Program may affect your eligibility for certain licenses, including a Commercial Driver's License (CDL) and/or a Firearm License.
Please consider this when making your decision and consult the appropriate authority if you have questions.
If a court or other authority challenges your certification by us, it may shift the risk/benefit calculation and we will be obligated to terminate your certification.