2024 CannXperience Pre-Qualification Appointment Form

Final Step

Signature and Submission
Type and sign your name below to indicate consent for a medical marijuana physician to contact you.
Date*

MonthDayYear
I am currently a Florida resident.
If the patient you are applying for is a minor, the parent or guardian must sign below to consent to the minor receiving recommendations for treatment.
Your Name

First NameLast Name
Patient's Signature*
Parent/Guardian Signature
I plan to pay for my MMJ evaluation by:*

Credit CardCashCredit from my care giver.
Upload valid photo I.D.

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Enter the message as it's shown*
Should be Empty:

Register and Pre-Qualify for MMJ Card