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Maryland Medical Cannabis Patient Certification Examination
Legal Name
*
First Name
Last Name
Preferred Name
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Pronouns i.e she/her, they/them, he/him
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Front and Back of Maryland State Issued ID
*
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Select your certification status
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New certification
Recertification
What is your MMCC ID number?
*
For what reason are you seeking certification for medical cannabis?
*
Select your qualifying condition
*
Please Select
Cachexia
Anorexia
Waisting Syndrome
Severe or Chronic Pain
Severe Nausea
Seizures
Severe Persistent Muscle Spams
Glaucoma
Post Traumatic Stress Disorder
Other Chronic Medical Condition
Upload any Proof of Diagnosis i.e prescriptions or medical records
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Please list your past medical history and any medical conditions for which you are seeing a medical care provider (i.e asthma, diabetes, bronchitis, high blood pressure)
*
Please list your past mental health history and mental health conditions for you are seeing a mental health provider (i.e. PTSD, anxiety, depression)
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Do you have allergies to foods or medications? If yes enter them below. If no, write "None"
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Do you agree to not drive or operate heavy machinery while using medical cannabis?
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Do you agree to safely store medical cannabis and keep out of reach of children and animals?
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Do you agree that use of medical cannabis will postively impact your quality of life and improve the condition for which you are seeking medical cannabis certification?
*
Signature
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