EmailMe Form - COMP Patient Application Form

This information is seen by only one person,
(Chief Executive Volunteer)

This information is destroyed, upon confirmation by your doctor. (Will hold up to, 30 days. Pending confirmation)

Name *

First Last

Email *

Confirm

Verify your applicable diagnosed illness. *

State issued photo identification *

Medical cannabis certification. *

Documentation, or certification, of illness & diagnosis. *

Please provide any form of documentation, or physicians statement.

Physician's Name *

Physician's city and state of Practice *

Name of Clinic, Hospital or Practice.

If applicable

We can not provide medicine without verification by your physician.

You must inform your physician, authorizing our pending inquiries, of your condition and status.

We will allow up to 30 days for verification. *

Yes, I understand

Do we have your authorization to contact your physician for verification of these facts? *

Yes

IF APPROVED

1. You will be contacted by email.
2. You will be added to our "COMPatient" list, for 6 months.
3. You may order up to 4 ounces, each month, of any cannabis product from COMP patient order form.
4. You are only responsible for any delivery or courier fee.

You must reapply every 6 months to renew.