Membership Application Form

Membership Application Form

Complete the form below and be sure to upload the required files, photo ID and Doctor's Recommendation at the bottom of the form.
Medical Condition*
Medical Recommendation Signed Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Doctor's Name*

First NameLast Name
Doctor's Phone Number*
Please enter a valid phone number.
How did you hear about Synergy Wellness?*
Are you participating in the Summer Referral Program? Yes/No?
I understand and agree as follows:
I am a qualified patient protected by California Health and Safety Code 11362.7, Proposition 215 and Senate Bill 420. My Doctor has recommended the use of medicalcannabis and provided written documentation of such recommendation. My doctor will review my case on a yearly basis. Per the relevant sections of California law, I am able to possess, use, and cultivate cannabis for medical purposes. I agree not to sell Synergy Wellness products to third parties. I agree to follow all the rules and guidelines of the collective.

Disclaimer – General Release, Indemnification and Hold Harmless Clause:

I, Being of lawful age and sound mind, do now release, acquit and forever discharge Synergy Wellness from all actions, claims, demands, or damages accruing to me from any known or unknown injury, loss or damage sustained by or to me. This release shall remain if force and run concurrently with my membership. I further agree to indemnify and hold harmless Synergy Wellness from any injuries or damages resulting from use or misuse of the medical cannabis products obtained from the collective.

I, as a member of Synergy Wellness Collective, have been advised at the onset of accepting membership, that any representations or recommendation made by the staff at Synergy Wellness is not an examination, diagnosis, or a prescription by a person licensed to practice medicine in this state and therefore must not be regarded as medical opinion. In addition, I acknowledge that I am not employed by any law enforcement or regulatory agencies.

I hereby sign and agree to join the Synergy Wellness collective.
Signature

Clear
Signed Name*

First NameLast Name
Signed Date*

MonthDayYear
Date
Scan or photograph your documents, upload below, then click “Submit” to complete your application.
Upload Photo ID / Driver's License*

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Upload Doctor's Recommendation*

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Should be Empty: