Patient Registration Form

New Patient Registration
Name *

First Name Middle Initial Last Name Suffix
Gender *
Preferred Pronouns *
Email *
Phone Number *
(808) 123-1234
Preferred Contact Method *

Email Phone
State of Hawaii, Department of Health required information. Noa Botanicals keeps all patient information confidential and will contact patients only when required (product recalls, lost personal items, etc.)

Please enter your Drivers License or ID information.
Drivers License / ID Number *
Drivers License / ID State *
Expiration Date *
MM/DD/YYYY
Date of Birth *
MM/DD/YYYY
Current mailing address *

Street Address

Street Address Line 2

City State

Zip Code

Consent Form
- I attest that I will not engage in the diversion of cannabis. I understand that fraudulent distribution or resale of cannabis is a felony.
- I understand that when under the influence of cannabis driving is prohibited and machinery should not be operated.
- I understand cannabis, including medical cannabis produced by Noa Botanicals, should be kept away from children.
- I acknowledge that Noa Botanicals does not provide medical advice.
- I acknowledge that law prohibits photography and video recording of any kind in the dispensary.
- I acknowledge consumption of cannabis or cannabis manufactured products on the premises of the dispensary is prohibited.
- I understand there may be health risks associated with using cannabis, including cannabis produced by Noa Botanicals.
- I understand I may not distribute cannabis to any other individual.
- I agree not to bring any weapons or anything that can be used as a weapon into Noa Botanicals facilities.
- I understand that I must have a valid government-issued identification and a valid Hawai'i medical 329 card during every visit to the Noa Botanicals dispensary.
- I acknowledge that I may not purchase more than four ounces of cannabis in a fifteen-day period from any dispensary.
- I always agree to abide by Hawai'i law regarding my use of medical cannabis and hereby release and waive all claims against Noa Botanicals from all liability related to my use of medical cannabis.
By signing, I acknowledge that I fully understand and agree with the terms and conditions stated above. *

Clear

Would you like to sign up for our Loyalty Program to earn points and discounts as you shop? *

Yes, I want to earn points to receive extra special discounts and exclusive offers No :(
Should be Empty:

New Patient Registration