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Marijuana Club Startup Guide

Patient Registration Form

(Marijuana Club Name)

(Marijuana Club Address)

___ Patient   ___ Caregiver   ___Renewal

First Name: _______________ Middle: _____________ Last: _________________

California Drivers License  ___ California ID: ____ ID Number: _____________________ 

Address: _____________________________________________

City: _______________________ State: _________  Zip: _________

Phone Number: ___________________ Email Address: _________________

Doctor Name: _______________________________________________

Doctor Address: ______________________________________________

City: _______________________ State: _________  Zip: _________

Doctor Phone: ___________________  Doctor Fax: _______________

Last Visit Date: ______________  Recommendation Expires: ______________

I hereby authorize my treating doctor to release medical information regarding my diagnosis and condition to (Marijuana Club Name).

Signed: ______________________________ Date: ____________________________

I understand and agree as follows:

I am a qualified patient protected by California Health and Safety Code 11362.7. et. seg., and Senate Bill 420. My doctor has recommended the use of medical mariuana and provided written documentation of such recommendation. My doctor will review my case on a yearly basis. Per the relevant sections of California law, I am able to legally possess, use, and cultivate cannabis collectively for medical purposes. I designate (Marijuana Club Name) as my care providers. I agree to follow all the rules and guidelines of the collective and pay reasonable compensation and/or volunteer for other services and activities provided by the collective.

Signed: _____________________________  Date: ________________________________

For Office Use Only

Date and Time Verified: ___________________  Verified by: __________________________

Not Verified  Date: _______________  By: __________________________________

Notes: _________________________________________________________________


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