Complete this form for an appointment
Exactly As It's Written on Your Driver's License/State ID
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First Name
Middle Name
Last Name
DATE OF BIRTH
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
MAILING ADDRESS
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMAIL ADDRESS: REQUIRED IF USING EXPRESS SERVICE
MMP CARD STATUS:
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I CURRENTLY HAVE A VALID MMP CARD
MY MMP CARD IS EXPIRED
THIS IS MY FIRST MMP CARD
WHY DO YOU WANT TO USE MEDICAL MARIJUANA?
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SECTION B: PERSON ALLOWED TO POSSESS PLANTS
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I AM MY OWN CAREGIVER
I HAVE A CAREGIVER/NOT MYSELF
CAREGIVER INFORMATION: FULL NAME, DOB, ADDRESS, PHONE, EMAIL
SELECT APPOINTMENT DAY
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FRIDAY, NOVEMBER 8th, 2024. Calling 12 noon to 8pm.
MONDAY, NOVEMBER 11th, 2024. Calling 12 noon to 8pm.
TUESDAY, NOVEMBER 12th, 2024. Calling 12 noon to 8pm.
WEDNESDAY, NOVEMBER 13th, 2024. Calling 12 noon to 8pm.
THURSDAY, NOVEMBER 14th, 2024. Calling 12 noon to 8pm.
SELECT YOUR SERVICE: EXPRESS SERVICE IS 72 HOURS TURN AROUND.
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$125 EXPRESS SERVICE: We take care of EVERYTHING.
$70 SELF-SERVICE: You submit your application and pay an addition $40 to LARA.
$100 FOR MINORS ONLY, required TWO DOCTORS.
TEXT A COPY OF YOUR DRIVER'S LICENSE AND MMP CARD TO:
(616) 719-0441
Please verify that you are human
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Submit
Should be Empty: