Telemedicine Request (standalone) - Affordable Marijuana License

M-Th: 8AM-3:30PM Sat: 8AM-12PMPLEASE TEXT US AT 904-586-0041main@affordablemarijuanalicense.com2624 Atlantic Blvd Suite #5Jacksonville, FL 32207

Thank you for your payment. Your transaction has been completed, and a receipt for your purchase has been emailed to you. Please complete the below form with your patient details.

telemed progress note with no redirect to consent form

Patient First Name(Required)

Patient Last Name(Required)

Preferred Name

Date of Birth(Required)

Gender on Driver's License(Required)

Street Address(Required)

City(Required)

Zip Code(Required)

Phone(Required)

Email(Required)

Please List Your Medical Conditions(Required)

Please select a recommendation package(Required)

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 300 day / 21000 70 days Edibles 25 day / 1750 70 days Oral 25 day / 1750 70 days Sublingual 0 Topical 0 Total 350 day / 24500 70 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(Required)

Patient ID #(Required)

From your medical marijuana card

Next you will be redirected to our document signing service so you can complete the medical marijuana consent form. Please initial all boxes, sign and date at the bottom. This is required to request a telemedicine visit. After that you are all done and we will contact you to confirm your appointment.

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