Refill Request Form | Express Marijuana Card

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Name *

First

Last

Patient Number(begins with P)

Email *

Phone *

Address *

Address Line 1

City

State

Zip Code

Date Of Birth *

Exact Date Your Recommendation Order Expires *

What is the "Expiration Date" of your State issued Medical Marijuana Use Registry ID Card? *

What is your gender? *

Male
Female
Other

Do you need any changes or adjustments to your recommendation order? (Please list below) *

Yes
No

Have you experienced a reduction in the use of controlled substances or other pain medications during the course of your use of Medical Cannabis? (Please describe) *

Yes
No

Have you been able to reduce the dosage or eliminate the use of any other medications because of Medical Cannabis use? If so please specify which ones and by how much *

Yes
No

Have you had any allergic reactions to or adverse side effects from Medical Cannabis that caused you to stop its use? If yes, describe said effect *

Yes
No

Please list all medications and dosage amounts you were taking "prior" to the start of medical cannabis treatment

Please list all medications and dosage amounts you're "currently" taking (NOT INCLUDING MEDICAL CANNABIS)

Please list the most important symptoms which were improved or eliminated with Medical Cannabis use

RENEWALS

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