Online Medical Card ( MMJ )

Embrace the Path to Wellness: Your Journey Starts Now!

First Name*

Middle Name

Last Name*

Email*

Phone*

Recommendation State*

Your Driver's License NUMBER. or State ID NUMBER*

Gender*

Date of Birth*

Referred By

If you have already registered at Pennsylvania medical marijuana program website and have a patient ID number, please provide us with your patient ID number here * Please click here if you don't have the identification number and proceed with your application without it

What are your allergies? (If any)

What medical condition do you want to use cannabis for?

Address (please include apartment / suite number if any)*

City*

State*

Zip*

Last 4 Digits of Your SSN Note : As per the requirements of the state’s medical marijuana program, the doctor needs the last four digits of your Social Security Number to certify you as a Medical Marijuana Patient.

QUALIFYING CONDITIONS

Pick from the list given below. If your medical condition is not mentioned in the list, select 'other'.

UPLOAD DRIVER'S LIC. OR STATE ID *

In order to verify your legal name and identity, you must upload a government-issued photo ID card such as a driver's license or passport.

Do you have a pet? No     Yes
Do you grow or plan to grow your own plants now or in the future? No     Yes
Do you have problems focusing, or have symptoms similar to attention deficit disorder? No     Yes

PATIENT'S SIGNATURE

By electronically signing this document, you declare that the information on this form is true and correct.

Additionally, you are also aware that your recommendation may be revoked at any time if you misrepresented yourself on this form.

Note: Filling out this questionnaire does not guarantee a medical marijuana recommendation.

I give my consent to telemedicine.

(Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care.)

I declare the following to be true:

I am over the age of 18
I don't have schizophrenia and I don't have hallucinations
(For females only) I am not pregnant

I agree to the terms and conditions*

Use your mouse, finger or stylus to add your signature.