NEW PATIENTS CAN COMPLETE PAYMENT THROUGH THIS FORM ONLY FOLLOWING INTERVIEW AND INITIAL CERTIFICATION BY PHYSICIAN

If patient agrees, physician will certify for 3 ounces/month x 6 months. Hit PayPal or credit card checkout payment bar and pay the $199 fee. Then, complete the submission process by hitting the Submit button on the very bottom of form. Office will be automatically informed, and physician will certify you ASAP and send you the necessary email with all the ID numbers you will require to register at website:

njmmp.nj.gov

 

 

PLEASE ALERT US IF YOU ARE USING SOMEONE ELSE'S PAYPAL ACCOUNT - WE NEED TO KNOW WHO THE PAYMENT IS FOR !!

Patient agrees - by signing below - that physician has counseled patient regarding potential adverse effects of marijuana and he/she understands that a risk & benefit exists even in the "medical" use of cannabis. Patient agrees to inform physician of any interval change in symptoms, other diagnoses, and medicine changes should they occur between certification evaluations. Patient agrees to comply with the every 3 to 6 month check in/recertification process as required by the State of New Jersey during the State and/or nationally defined Covid-19 pandemic state of emergency and whatever is the defined state policy in its aftermath.

Please know your certification or card renewal/expiration date (it is your responsibility), and, please, do not wait until you are on line at the dispensary to call our office at the last minute "emergently". 

Patient agrees that he/she is responsible to obtain/keep-on-file their personal certification registry and reference numbers, and that physician's office is not responsible for "keeping, remembering and reminding of" this for him/her. Please do not lose or misplace these important numbers.