$50 Special - Affordable Marijuana License

Please list your current medications*

We cannot see patients that are pregnant or beast-feeding. If you have questions please call our office at 904-586-0041. Thank you for understanding.

Do you have any other qualifying conditions?*

Please list the medications you are allergic to*

Please provide details of your hospitalization(s) with dates.*

Please list your surgeries with dates they were performed.*

Inhalation 200 day/ 14000 70 days

Edibles 50 day / 3500 70 days

Oral 50 day / 3500 70 days

Sublingual 25 day / 1750 70 days

Topical 25 day / 1750 70 days

Total 350 day / 24500 70 days

Inhalation 200 day/ 14000 70 days

Edibles 50 day / 3500 70 days

Oral 50 day / 3500 70 days

Sublingual 0 day / 0 70 days

Topical 50 day / 3500 70 days

Total 350 day / 24500 70 days

Inhalation 0

Edibles 50 day / 3500 70 days

Oral 150 day / 7000 70 days

Sublingual 150 day / 7000 70 days

Topical 50 day / 3500 70 days

Total 350 day / 24500 70 days

Inhalation 200 day / 14,000 70-day

Edibles not applicable

Oral 150 day / 10,500 mg 70-day

Sublingual not applicable
Topical not applicable

Total 350 day / 24,500 70-day

Smoking 2.5 oz every 35 days

Inhalation 300 day / 21000 70 days

Edibles 50 day / 3500 70 days

Oral 0

Sublingual 0

Topical 0

Total 350 day / 24500 70 days

Inhalation 200 day / 14000 70 days

Edibles 50 day / 3500 70 days

Oral 100 day / 7000 70 days

Sublingual 0

Topical 0

Total 350 day / 24500 70 days

Inhalation 350 day / 24500 70 days

Edibles 0

Oral 0

Sublingual 0

Topical 0

Total 350 day / 24500 70 days

Please pick a date you would like for your appointment*

Please be aware you will need to do an exemption request and renew it to keep the higher limit.

After you press ‘Submit’ you will be redirected to our document signing service to complete the medical marijuana consent form. Please initial all boxes, then sign and date at the bottom. Then you will be redirected to our payment platform to pay for your appointment. After that you are all done and we will contact you to confirm your appointment.

Comments

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Patient Date of Birth*

Your birthday

How much product do you use at a time?*

Please explain your current regimen below?*

What about this route or product is better for you?*

Why do you choose it over other products?*

How do you feel this increase will better your treatment options?*

Have you had an exemption before?*