Patient Intake Form

License To Use

www.licensetouse.com

license2use@gmail.com

(580)774-7402
Patient Intake Form

Fill the form below to book your appointment!
Name*

First NameMiddle NameLast NameSuffix
How did you hear about us?*

DispensaryWord of MouthSocial MediaOther
Please list the dispensary below - if you're unsure, type "N/A"*
I am a...*

New PatientRenewal
Date of Birth*

DayMonthYear

Contact Information
Email*
example@example.com
Is this email associated with your OMMA account?*

YesNoI'm not sure
If you know your OMMA password, enter it here:
Phone Number*

Mailing
Mailing Address

Make sure the address you enter below is the address you want your card mailed to!
Enter your mailing address here:*

Street Address

Street Address Line 2

CityState

Zip Code
Physical Address (This address should match the address on the minor patient's photo ID, parent or gaurdian's photo ID)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Documents & Discounts
Patient Headshot

Please upload a clear, well-lit image of yourself at least 3 feet from the camera lens. Remove your glasses, hats, medical equipment, and jewelry. Use a plain background, if possible.
Upload your Patient Headshot here:*

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Proof of Identity
Which type of identification document are you uploading?*
Upload a photo of your Driver's License, Passport, State, or Tribal ID**

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Proof of Residency

If you are uploading a tribal ID, or passport as proof of identity, you must provide additional documentation for proof of residency. Proof of residency can be any one of the following:
- Previous year's Oklahoma tax return
- Last month's utility bill
- Residential property deed
- Rental agreement
Please provide additional documentation for proof of residency here.

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*Tribal identification cards approved for identification purposes by the Oklahoma Department of Public Safety:

United States Bureau of Indian Affairs identification card or an Oklahoma tribal photo identification card: Muscogee (Creek) Nation of Oklahoma, Kiowa, Comanche, Apache of Oklahoma, Absentee Shawnee, Cheyenne-Arapaho, Choctaw, Delaware, Caddo Nation of Oklahoma issued on or after January 8, 2008
Discounts
Do you have Soonercare, Medicare, or 100% Disabled Veteran Status?*
Proof of Soonercare, Medicare, or 100% Disabled Veteran Status grants you an 80% discount on your OMMA State Fee, read more about which documents are accepted by OMMA:

Front of your Medicare card, Medicaid (Soonercare) enrollment letter, Veteran Status-letter from the VA with 100% disability status noted. *If you cannot upload these files today, please email them to license2use@gmail.com before your appointment.
Upload Proof of Soonercare, Medicare, or 100% Disabled Veteran Status**

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I acknowledge that my total will be $154.65 unless I provide proof of Soonercare, Medicare, or 100% Disabled Veteran status. *
*Links to Soonercare, Medicare, and Veteran go here*
If you have any notes or questions regarding your appointment or application process, please leave them here.
These will be addressed during your appointment. If you have an urgent question, please call 580-774-7402 or email license2use@gmail.com
Attestations
Required*

Choose An Appointment Time
Your payment will be processed at the time of your virtual appointment to cover your doctor recommendation and state fee. Altogether, your total will be either $154.65, or $69.58 if you have proof of Soonercare, Medicare, or are status as a 100% disabled veteran. Please have your payment information and state ID ready at the time of your appointment.
Preferred Appointment Date *
Should be Empty:

Patient Intake Form

Mailing Address

Patient Headshot

Proof of Identity

Proof of Residency

*Tribal identification cards approved for identification purposes by the Oklahoma Department of Public Safety:

Discounts

Attestations