GEORGIA MMJ RENEWAL
Provide Some Basic Medical History and Book a Virtual Appointment with a Licensed Medical Marijuana Doctor.
Name
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First Name
Last Name
State
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Georgia
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Date of Birth
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Month
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Day
Year
Date
Gender
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Male
Female
Other
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Email
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example@example.com
Are you taking any medications?
*
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Yes
No
What medication are you currently taking?
Have you ever experienced hallucinations before?
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Yes
No
Have you ever been diagnosed with schizophrenia?
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Yes
No
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What is your medical history like?
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Cancer, when such diagnosis is end stage or the treatment produces related wasting illness or recalcitrant nausea and vomiting
Amyotrophic lateral sclerosis, when such diagnosis is severe or end-stage
Seizure disorders related to the diagnosis of epilepsy or trauma related head injuries
Multiple sclerosis, when such diagnosis is severe or end-stage
Crohn’s disease
Mitochondrial disease
Parkinson’s disease, when such diagnosis is severe or end-stage
Sickle cell disease, when such diagnosis is severe or end-stage
Tourette’s syndrome, when such syndrome is diagnosed as severe
Autism spectrum disorder, when (a) patient is 18 years of age or more, or (b) patient is less than 18 years of age and diagnosed with severe autism
Epidermolysis bullosa
Alzheimer’s disease, when such disease is severe or end-stage
AIDS when such syndrome is severe or end-stage
Peripheral neuropathy, when symptoms are severe or end-stage
Patient is in hospice program, either as inpatient or outpatient
Intractable pain
Post-traumatic stress disorder resulting from direct exposure to or witnessing of a trauma for a patient who is at least 18 years of age
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The $169 fee includes your consultation fee, physician copay, and the medical evaluation for your recommendation. PAYMENT IS FULLY REFUNDABLE IF YOU ARE NOT GET APPROVED
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169.00
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