Visiting Patient Form

Patient Information

Patient First Name *

Patient Middle Name

Patient Last Name *

Suffix

Street Address *Please enter the patient's Street Number and Street Name (or PO Box)

Unit Number

City *

State *

ZIP code *

Date of Birth *

Patient Phone Number *

Email Address *

Under the age of 18? *YesNo

Physically disabled? *YesNo

Description of Debilitating Medical Condition

ICD-10 Diagnosis Code or Description of Debilitating Medical Condition *Debilitating Medical Condition has the meaning ascribed in R.S. 40:1046(A)(2)(a)0 / 180

Therapeutic Marijuana Treatment Requested0 / 180

Medical Provider and Registry Information

Provider First Name *

Provider Middle Name

Provider Last Name *

Suffix

Street AddressPlease enter the provider's Street Number and Street Name (or PO Box)

Unit Number

City

State

ZIP code

National Provider Identifier Number (NPI)

Provider Phone Number *

Provider Fax Number

Medical Marijuana Recommendation Expiration Date *

State of Issuance *

Medical Marijuana Patient Registry ID Number (or equivalent) *

Today's Date *

Attestation *

I attest/certify that I have been diagnosed by a licensed physician with the debilitating medical condition listed above. I attest that I hold an active and valid medical marijuana registry card (or its equivalent) in another state district, territory, commonwealth, or insular possession of the United States. I further attest that I will not divert any medical marijuana dispensed by a Louisiana Marijuana Pharmacy to any person.

Once received and reviewed, your licensed physician will be contacted by our pharmacy for approval to dispense in Louisiana.

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Working Hours

M-F: 9:00am - 5:30pm

Sat: 9:00am - 1:00pm
(only pick-up orders)