Patient Application for Certification
This form is only for patients who are 21+ years old. For younger patients, please email info@cannafacilitator.com. COST: $50
Name + Last Name
*
Nombre
Apellidos
Local Address (where you are staying in Puerto Rico)
Línea 1
Línea 2
Pueblo
Estado
Código Postal
Phone number
*
-
Código
Teléfono
E-mail
Date of Birth
-
Day
-
Month
Year
DAY-MONTH-YEAR
Social Security Number
*
Eye Color
Brown
Blue
Green
Hazel
Black
Other
Height
Feet' Inches"
Weights
pounds (lbs)
¿Are you 21 years old or older? You MUST be 21+ to complete this form.
*
Sí
Condiciones de salud por las cuales se puede certificar
Alzheimer
Anorexia
Arthritis
Autism
Depression
Epilepsy
Fibromialgia
Glaucoma
Hepatitis C
Insomnia
Migranes
Spinal Cord Lessions
Anxiety Disorder
Periferal Neuropathy
Parkinson's disease
PTSD
HIV
Bipolar Disorder
Other conditions that may cause caquexia, chronic pain, severe nausea or persistent muscle spasms
Degenerative Diseases (Amyotrophic Lateral Sclerosis y Multiple Sclerosis)
Incurable Disease that requires paliative care
Cancer and chemotherapy
Disorders related to an HIV positive diagnosis
Inflammatory Bowel Disease
Other
Please provide a valid ID with photo (passport, driver's license, Real ID)
*
Browse Files
Cancel
of
Please provide a copy or photo or the Cannabis ID License from your state
*
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Cancel
of
Where you referred? (If so, name of the Dispensary)
Other
Other Payment option:
Paypal: tugestorapr1@gmail.com
Other
Firma / Signature
Mis Productos
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PATIENT CERTIFICATION
$
50.00
$
50.00
Total
$
0.00
Detalles de Tarjeta de Crédito
Nombre
Apellido
Número de tarjeta de crédito
Security Code
Card Expiration
Submit
Should be Empty: