Medical Marijuana Information Form

YOUR APPOINTMENT IS NOT IN PERSON, IT'S OVER THE PHONE.
Patient's Name: Type it out EXACTLY as it appears on your Driver's License*

First NameMiddle NameLast NameJR, SR, I, II, III
Date Of Birth*

MonthDayYear
Date
Primary Phone Number*
Please enter a valid phone number.
Address*

Street Address

CityState

Zip Code
Email: REQUIRED IF YOU ARE DOING THE EXPRESS SERVICE
example@example.com
MMP CARD STATUS*

This will be my FIRST MMP CARDI currently have OR had and MMP CARD (TEXT COPY OF MMP CARD BELOW)
What is you Medical Condition for Medical Marijuana Use?*
SECTION B: PERSON ALLOWED TO POSSESS PATIENT'S PLANTS (REQUIRED)*

I am MY OWN Caregiver.I have a Caregiver, NOT MYSELF.
IF YOU HAVE A CAREGIVER: Name, Address, Phone #, Email Address.
SELECT YOUR SERVICE:*

FULL SERVICE $125: ONE PAYMENT, WE TAKE CARE OF EVERYTHING FOR YOU.SELF-SERVICE $70: YOU WILL SUBMIT ALL YOUR DCOUMENTS TO LARA AND THEN PAY AN ADDITION $40 LICENSE FEE.MINOR PATIENT $100: THIS FEE COVERS 1 OF 2 DOCTORS. AN ADDITIONAL LICENSE FEE OF $40 WILL BE PAID TO LARA.
SELECT AN APPOINTMENT DAY: ALL APPOINTMENTS ARE OVER THE PHONE.*

MONDAY, FEBRUARY 6th, 2023: CALLS MADE 3:00PM TO 8:00PMTUESDAY, FEBRUARY 7th, 2023: CALLS MADE 3:00PM TO 8:00PMWEDNESDAY, FEBRUARY 1st, 2023: CALLS MADE 3:00PM TO 8:00PMTHURSDAY, FEBRUARY 2nd, 2023: CALLS MADE 3:00PM TO 8:00PMFRIDAY, FEBRUARY 3rd, 2023: CALLS MADE 12:00PM TO 4:00PM
TEXT A PHOTO OF YOUR DRIVERS LICENSE TO AND MMP CARD:

(616) 719-0441
Enter Captcha Below For Verification*
Should be Empty:

YOUR APPOINTMENT IS NOT IN PERSON, IT'S OVER THE PHONE.