Cannabis Medical, LLC - Membership Application

If you need a "Care Giver" you must provide us with your State of Colorado Medical Marijuana Registry number (this is a state requirement). Then a qualified representative from Cannabis Medical will contact you within 72 hours to schedule an intake process interview.

Name:
Street Address:
Date of Birth:
City, State, Zip:
Phone :
Phone to call back for immediate response :
Email Address:
Medical Condition:
How do you prefer to ingest your medicine?
Enter your Colorado Medical License Number:
How does cannabis effect your condition?
I verify that all information and all documents regarding my condition submitted to Cannabis Medical are factual. Cannabis Medical assures that all of your provided information will be kept confidential. Member's Initials: I made this appointment of my own free will and acknowledge that no effort has been made by Cannabis Medical to encourage me to procure or use this product.

	info@cannabismedical.com Denver, CO - USA 303.912.2013
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