Medical Marijuana card Intake form
COMPLETE THIS FORM ONLY AFTER YOU HAVE SCHEDULED AN APPOINTMENT.
Last Name , First Name *
Your answer
Date of Birth *
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Phone number *
Your answer
Email *
Your answer
Address *
Your answer
Name of County *
Your answer
How long have you lived in Georgia *
Your answer
The medical diagnosis qualifying you for medical marijuana *
Your answer
Date this Medical problem started *
MM
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Submit
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