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Patient's Form

Please select the condition for which you seek medical marijuana. 

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For how long you are experiencing it?

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If it's chronic pain, what is the cause of it?

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Are you taking any other medication?

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Have you ever been diagnosed with schizophrenia?

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Have you ever experienced hallucinations before?

 

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Do you smoke cigarettes?

 

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Do you drink alcohol?

 

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The patient tried and had a failure of other alternatives, and appropriate time was spent on discussing the risks, including but not limited to addiction.

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Avoid operating heavy machinery and driving under the influence of cannabis.

 

I will not grow cannabis in my household.

 

Keep away from children.

 

Upload a valid New York State ID

Your information is stored safely and

securely in the HIPAA - compliant database.

 

Take a clear picture of your identification.

Valid state ID/License, Passport, US Viasa.

The other US government-issued ID, bills

are ok to upload too!

 

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Upload a selfie for your new cannabis ID card

 

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We take privacy and security very seriously. We implement state of the art security and encryption protocols to assure that data integrity and privacy is maintained. As a result, BlazeMD complies with HIPAA and HITECH requirements.