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Patient's Form

Please select the condition for which you seek medical marijuana. 


For how long you are experiencing it?


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


Are you taking any other medication?


Have you ever been diagnosed with schizophrenia?


Have you ever experienced hallucinations before?



Do you smoke cigarettes?



Do you drink alcohol?



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.


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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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.