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Jacksonville, FL 32207
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Medical Marijuana Exemption Request
"
*
" indicates required fields
Patient Full Name
*
First
Last
Patient Date of Birth
*
MM slash DD slash YYYY
Your birthday
Patient Phone #
*
What types of products/routes are you using?
*
Inhalation
Edibles
Oral
Sublingual
Topical
Smokable
What routes are you requesting the exemption form for?
*
Smoking
Oral
Edibles
Topical
Sublingual
Inhalation
How often do you use your products?
*
Once daily
Twice daily
Every few hours
Other
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?
*
Name
First
Last
Have you had an exemption before?
*
No
Yes
A disclaimer..
*
An exception is created on open orders, once the orders expire the exception will as well. To renew the exception you will need to fill out this form, have new active orders, and do a visit each time.
I understand.
Email
This field is for validation purposes and should be left unchanged.
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