PHYSICIAN APPLICATION
GreenLeaf Consultants is helping hundreds of patient in Maryland get access to the Medical Cannabis Program through evaluations and recommendations. If you are a physician and would like to join our growing team please fill this form and a member on our team will contact you. JOIN OUR TEAM TODAY!
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First Name: *
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Middle Initial:
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Last Name: *
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Date of Birth: *
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Address 1: *
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Address 2:
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City: *
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State: *
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Zip Code: *
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Phone Number: *
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Speciality: *
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Medical or Graduate School: *
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Degree:
Year of Graduation: *
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Maryland Board of Physicians (MBP) License Number:
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Controlled Dangerous Substances (CDS) Registration Number:
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CDS Expiration Date:
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Select Medical Conditions for which written certificates will be issued: *
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Do you prefer to supply your license number over the phone? Check this box and we will give you a call.
I attest that my Maryland license to practice medicine is active, unrestricted and in good standing. *
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I attest that I am registered to prescribe controlled substances by the State. *
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I hereby certify that before issuing a written certificate I will have a bona fide physician-patient relationship with the qualifying patient and will perform a full in-person assessment on a yearly basis. *
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I declare and affirm under penalty of perjury that the statements made herein are true and correct to the best of my knowledge, information and belief. *
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Thank you for Applying!
Everyone will receive consideration without discrimination of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.
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