Patient Med & Rec Registration – State Registration MMC

Recreational And Medical Cannabis Consumer Registration Form

Licenced State Dispensary Notice: Office Of Cannabis Management

Due to the new state regulation on dispensaries all customer who purchase cannabis products from any dispensary are required to pay a refundable state registration fee.The fee is required to confirm if you are the owner of the state ID or Drivers License which you provide during the registration process. The state fee is refundable upon delivery in cash by the delivery agent in charge of your package.

Name

Date of Birth

Phone Number

Home Address

Have your ever use cannabis? *

Which dispensaries have you visited in your state? *

IF Yes, How often? *

What do you use cannabis for? *

Are you a veteran of the Armed Service? *

Upload front photo of your state ID or Drivers License *

Upload Back photo of your state ID or Drivers License *

Half passport size photo of your self *

Refundable State Registration Fee $299.99

HIPAA Compliant

Registration MMC is HIPAA compliant and uses Armor.com’s powerful HIPAA, HI-TRUST solution, learn more at stateregistrationmmc.com

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Our cloud based solution can be accessed at anytime by any device and is easy to use for both clinicians and patients

BAA

Registration MMC has a BAA backed by one of the leading HIPAA compliant hosting and security companies, stateregistrationmmc.com