Registration
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First Name
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Last Name
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Date of Birth
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Medical Marijuana ID (if known)
Address
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City
State
Zip
Email
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Phone Number
Qualifying Diagnosis
Amyotrophic lateral sclerosis.
Anxiety disorders.
Autism.
Cancer, including remission therapy.
Crohn’s disease.
Dyskinetic and spastic movement disorders.
Epilepsy.
Glaucoma.
HIV / AIDS.
Huntington’s disease.
Inflammatory bowel disease.
Intractable seizures.
Multiple sclerosis.
Neurodegenerative diseases.
Neuropathies.
Parkinson’s disease.
Post-traumatic stress disorder.
Sickle cell anemia.
Terminal illness.
Tourette syndrome.
Severe chronic or intractable pain.
Damage to the central nervous system (brain-spinal cord).
Opioid use disorder.
Physician(s) currently managing qualifying condition(s)
Primary Care Physician
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