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___ 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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