ONLINE MMJ INTAKE FORM

Email*

example@example.com

DO YOU ALREADY HAVE A PORTAL ACCOUNT FOR THIS EMAIL ADDRESS?*

There can only be one portal account registered to each unique email address.

PORTAL ACCOUNT PASSWORD : password required*

Full Legal Name:*

First NameMiddle NameLast NameSuffix

DATE OF BIRTH*

SOCIAL SECURITY #:*

Phone Number*

Please enter a valid phone number.

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your mailing address the same as your physical address?*

YESNO

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DO YOU INTEND TO CULTIVATE MARIJUANA*

NOYES

IF YES, PLEASE PROVIDE SOME DETAILS OF YOUR DESIRED GROW SPACE:*

PLEASE DESCRIBE INDOOR/OUTDOOR, BRIEFLY DESCRIBE ROOM OR STRUCTURE & HOW YOU INTEND TO SECURE THIS ROOM/STRUCTURE. IF YOU INTEND TO CULTIVATE AT A LOCATION OTHER THAN YOUR CURRENT RESIDENCE PLEASE PROVIDE ADDRESS OF INTENDED CULTIVATION LOCATION.

UPLOAD A CLEAR IMMAGE OF YOUR STATE ISSUED, CURRENT ID*

Photo must be a sharp, clear image with no part of the ID obstructed.

UPLOAD A "DRIVERS LICENSE" STYLE PHOTO OF YOURSELF*

Photo must be a sharp, clear image of yourself. Your photo must start mid torso and extend up past the top of your head. Your eyes must be open. The background of your image MUST be a plain white or off white color ONLY. Please do not wear any glasses or hats in your photo.

Any additional details or concerns?

Please ensure all info entered into this form is accurate. If errors are made on this form it can delay the processing time of your application.

Please ensure the phone number and email address you provide is current and accurate. These are the only methods of communication we have in the event we need to contact you about your application process.

Once you pay for this service it is non-refundable. Once you speak with the Dr we have to get the forms filed in a timely mannor according to the law. That is why accuracy on this form and good contact information is important.

If you currently do not have a poral account we will have to make one for you. Your email address will be your user name. You will have to be able to confirm your email address durring this process. This is another example of why being available for contact is important.

Once you finish this process today, confirm your email and televisit with the doctor there is nothing you need to do but wait for you approval email from the DHHS.

Upon completion and submission of this form you will be redirected to our doctor's website (The Green Pot Clinic) where you can set your appointment to speak with the doctor, at your convience, via a Televisit appointment.

The fees quoted below cover ALL your state medical paitent fees + the filing fees for your portal work. You will be required to pay the doctor (currently $75) for his services at the time of setting your virtual appointment.

If you have any questions or concerns before the process or during the process feel free to reach out any time. 417-454-4840 (Mon-Sat 11am-7pm) or sleepytreesgrowsupply@gmail.com

I have read and agree to the above statements:*

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SERVICES:

New / Renew Medical Patient CertificationMedical patient cert. 3 year license. This fee is for all state fees + portal work and filing.

$65.00

New / Renew Medical Patient Certification + CultivationMedical patient cert + medical cultivation. 3 year license. This fee is for all state fees + portal work and filing.

$120.00

Total

$0.00

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

MO MMJ Paitent Intake Form