MEDICAL INTAKE FORM
If available, please upload the latest medical documents related to your qualifying medical condition(s) in PDF or JPG format. Each File Size Limit: 1MB. You may also email them separately to: [email protected] or fax to: (516) 590-0198. Your medical records will be secure and confidential and will only be used to determine your eligibility for medical marijuana certification.

We will email you a HIPAA Medical Release form for you to complete, sign and send back to us. Please enter the full name and phone number of the medical provider whom you've treated with, who is most relevant to your qualifying condition.

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