Registration Form


Registration Form

Patient Information
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Referred to clinic by:



INSURANCE INFORMATION

(PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST.)

Primary Insurance
Secondary Insurance

IN CASE OF EMERGENCY

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Cannabis MD or insurance company to release any information required to process my claims.