Patient Information Doc Maker

Please fill in the following:

Legal Name:
Date of Birth:

Email: (This is how the Florida Department of Health (DOH) will communicate with you):

SS# (Required for registration into the MMUR-We promise to keep it safe and secure):

Address (Please Note: The address on your driver’s license is the only location the DOH will mail your official card to): City/State/Zip Code/County:

Telephone Number:

Alternate Contact Name:

Alternate Tel. No.:

Your weight: (Ibs)

If female, are you currently pregnant? Yes No
N/AYesNo

Release of liability:
| affirm that the information on this form is correct and that any medical history presented or discussed with the doctor is factual and complete. | do not plan or intend to use my physician’s recommendation for the purpose of illegally obtaining medical marijuana. Solely for verification and medical purposes, | authorize to converse with the physician, staff, and representatives of this HIPPA compliant practice regarding my confidential medical history and qualifying medical marijuana condition. | understand that | must be a Florida State resident to obtain approval or recommendation for the use of medical marijuana under the Compassionate Medical Cannabis Act SB 8-A-Medical Use of Marijuana.

| also affirm that | am interested to learn more about medical marijuana and how it may be used to treat my qualifying medical condition.

Signature:

Date: