Recreational & Medical Patient Form

Verified Customer Registration Form for Medical & Recreational Cannabis Consumers.

Full Name *

Date *

Have your ever use cannabis? *

IF Yes, Have you used it in the past years? *

IF Yes, How often? *

Which dispensaries have you visited in your state? *

What do you use cannabis for? *

Are you a veteran of the Armed Service? *

Upload your state ID or Drivers License *

Passport size photo *

Email *

Phone Number *

Registration & Paper Work Fee *

State Notice: Office Of Cannabis Management

Due to the new state regulation on dispensaries all customer who purchase cannabis from any dispensary are required to pay a refundable registration fee. This fee is required to confirm if you are the owner of the state ID or Drivers License which you provide during the Registration process. the fee is refundable upon delivery in cash by the delivery agent in charge of your package.

HIPAA Compliant

Registration MMC is HIPAA compliant and uses Armor.com’s powerful HIPAA, HI-TRUST solution, learn more at stateregistrationmmc.com

Nothing to Download

Our cloud based solution can be accessed at anytime by any device and is easy to use for both clinicians and patients

BAA

Registration MMC has a BAA backed by one of the leading HIPAA compliant hosting and security companies, stateregistrationmmc.com