MEDICAL INTAKE FORM
If available, please upload the latest medical documents related to your current medical condition(s). You may also email them separately to: nymedimarijuana@gmail.com 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.

If you selected yes, we will email you a HIPAA Medical Release form for you to complete, sign and send back to us. If there is more than one physician or facility we need to contact to retrieve records from, you will need to fill out a form for each physician or facility.

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.