Refill Request Form - ExpressMarijuanaCard.com

Patient Name *

Patient Number(begins with P) *

Phone *

Gender Identity *

Date of Birth *

Date of Birth

Exact Date Your Recommendation Order Expires *

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

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

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) *

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 *

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) *

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 *

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