Doctor Registration

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Doctor Registration

We Value Your Privacy. We will never share or sell your information to anyone without your prior consent. This Form and website are secure and encrypted for your privacy.

Why Prescribe Medical Marijuana?

It is a fact that Doctors licensed to prescribe medical marijuana can help patients relieve pain and suffering from debilitating health conditions in many areas like epilepsy, migraines, tumors, autism and many forms of cancer.

First Name *

Last Name *

Primary Email *

Primary Phone *

Zip Code *

Experience *

Currently Registering Medical Marijuana Patients

Willing to Register Medical Marijuana Patients

Your Location(s) *

Hawaii Island

Kauai

Maui

Molokai

Niihau

Oahu

Other:

Required

Willing to Travel? *

Yes, I already do to support patients.

Yes

Maybe

Required

Would you like to meet caregivers? *

Yes

Any Special Instructions? Questions? Comments?

I understand that by submitting this form I am in no way creating a Doctor - Patient relationship. *

Yes

Required

Submit

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