EVEREST CANNABIS CO INFORMATION FORM

EVEREST CANNABIS CO INFORMATION FORM
Today's Date

Month Day Year
Date
Guest Name *

First Name Last Name
Phone Number (required for order updates) *

Area Code Phone Number
Guest Email (required for order updates) *
example@example.com
ADDRESS FOR DELIVERY: Must match address on valid ID or you must provide address verification in the form of a utility bill with Guest's name and the address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please upload a picture of your valid government-issued ID (Example: Driver's license or passport) **NOTE: THIS IS REQUIRED FOR BOTH RECREATIONAL AND MEDICAL DELIVERIES *

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Cancel of
Please upload a picture of a utility bill with your name if the address on your government issued ID does not match the delivery address

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Cancel of
NM Medical Cannabis Patient/Caregiver # (if applicable)
NM Medical Cannabis Card Expiration Date (if applicable)

Month Day Year
Date
Caregiver Name (if applicable)

First Name Last Name
Please upload a picture of your NM DOH Patient or Caregiver Medical Card

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Are you a US Veteran? (Veterans receive a 15% discount every day at Everest!)

Yes No
Please upload a picture of your military ID for verification

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Cancel of
Notifications:

I DO NOT wish to receive emails regarding specials and new products. I DO NOT wish to receive text messages regarding specials and new products.
I UNDERSTAND that Everest Apothecary will verify my information w/NMDOH *
I UNDERSTAND that neither Everest Apothecary nor the NMDOH can protect me from federal criminal prosecution of medical cannabis use or possession. *
I UNDERSTAND that Everest Apothecary is only a provider of medicinal cannabis and does not provide medical advice. *
COMPLETE THIS SECTION IF YOU HAVE OR ARE A REGISTERED CAREGIVER:

First Name Last Name
NM Medical Cannabis Patient #
Date

Month Day Year
Date
Expiration Date

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
DELIVERY INFORMATION
Please check the following boxes, acknowledging your understanding: *

Everest delivery drivers carry NO CASH. Payment must be made via credit or debit card. Everest delivery drivers are actively monitored by GPS at all times The individual that purchase our products for delivery must show a valid government issued ID prior to receiving the products from the delivery driver. No one under the age of 21 or without a valid medical cannabis card and matching ID will be allowed to order or accept delivery Everest will only deliver to a permanent home address. Guests must show proof of residency via government issued ID or a utility bill in order to schedule delivery
HIPAA INFO AND CONSENT FORM

The Health Insurance Portability and Accountability Act (HIPAA), Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. As a covered entity, we follow HIPPA guidelines and train our staff in the proper handling of your personal health information. Your health information cannot be used or shared without your written permission unless the law allows it.

What information is protected?
- Information your doctors, nurses, and other health care providers put in your medical record.
- Conversations about your care or treatment.
- Billing information about you.
- Most other health information about you held by those who must follow these laws
How does Everest Cannabis Co. protect this information?
- Our employees are HIPAA Certified.
- We will reasonably limit uses and disclosures to the minimum necessary to accomplish our intended purpose.
- Everest has procedures in place to limit who can view and access your health information
- Everest will not give information to your employer
- Everest will not share information about your health care or purchases
Everest Cannabis Co. follows additional HIPAA guidelines not listed here and upon request, would be happy to provide you with more details about our procedures.
By signing below, I fully understand and agree to all Everest Cannabis Co's Terms and Conditions. *

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EVEREST CANNABIS CO INFORMATION FORM

DELIVERY INFORMATION