First and Last Name (As it appears on your ID)
Date of Birth
MMJ Registration Number (Must be 20 digits)
MMJ ID Registration Expiration Date
Drivers License or Passport # (whichever you registered with)
State ID Expiration Date
Current Address (Your address must match the address on your driver's license. If they differ, please update in the registry or provide verification of current address at your next visit.)
Preferred Pronouns (Optional)
Preferred Name (Optional)
Emergency Contact (Optional)
Emergency Contact Name
Relationship to Patient
Caregiver Registration ID Number
Status (Select any that apply)
Have you used cannabis before?
If so, what is your experience with it?
A few times in your life
A few times a year
A few times a month
What type of medical cannabis are you familiar with or interested in?
Flower (Plant Material)
Do you have any allergies or are you prescribed any medication(s) that may cause adverse reactions to MMJ products that you would like for us to be aware of?
How did you hear about us?
Word of Mouth
Walk by/Drive by
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Nar Reserve's Patient Waiver of Liability and Hold Harmless Agreement.