Patient Registration
Personal Information
First and Last Name (As it appears on your ID)
Date of Birth
MMJ Registration Number (Must be 20 digits)
MMJ ID Registration Expiration Date
Drivers License or Passport # (whichever you registered with)
State ID Expiration Date
Current Address (Your address must match the address on your driver's license. If they differ, please update in the registry or provide verification of current address at your next visit.)
City
State
ZIP Code
Gender
Male
Female
Other
Preferred Pronouns (Optional)
Preferred Name (Optional)
Phone Number
Email Address
Emergency Contact (Optional)
Emergency Contact Name
Phone Number
Relationship to Patient
Caregiver (Optional)
Caregiver Name
Phone Number
Caregiver Registration ID Number
Current Address
City
State
ZIP Code
Other Information
Status (Select any that apply)
Indigent Status
Veteran Status
Terminally Ill
Industry Employee
Have you used cannabis before?
Yes
No
If so, what is your experience with it?
A few times in your life
A few times a year
A few times a month
Weekly
Daily
What type of medical cannabis are you familiar with or interested in?
Flower (Plant Material)
Edibles
Extracts
Tinctures
Topicals
Do you have any allergies or are you prescribed any medication(s) that may cause adverse reactions to MMJ products that you would like for us to be aware of?
Yes
No
Unsure
Please explain:
How did you hear about us?
Word of Mouth
Leafly
Social Media
Walk by/Drive by
Other
Please explain:
Opt-in to receive communications from Nar Reserve
By checking here, I attest to have read and agree to
Nar Reserve's Patient Waiver of Liability and Hold Harmless Agreement.
Signature:
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