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Online Registraition Form

Patient Information - Step 1
Name:
Address:
City:
State:
Zip Code:
Driver's License or ID Number:
Birthdate:
Telephone:
Email: (Administrative Use Only)


Doctor Information - Step 2
Doctor's Name:
Doctor's Telephone:

Docter's CA License #:

Statement/Letter's Date:

I authorize HAi to contact my physician for verification.


Medical Marijuana Identification Cards - If Available
MMIC Number:
Expiration Date:
Letter of recommendation and state-issued ID is still required when visiting.