Visiting Patient Form Capitol Wellness Picardy Location Patient InformationPatient First Name *Patient Middle NamePatient Last Name *SuffixStreet Address *Please enter the patient's Street Number and Street Name (or PO Box)Unit NumberCity *State *ZIP code *Date of Birth *Patient Phone Number *Email Address *Under the age of 18? *YesNoPhysically disabled? *YesNoDescription of Debilitating Medical ConditionICD-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 / 180Therapeutic Marijuana Treatment Requested0 / 180Medical Provider and Registry InformationProvider First Name *Provider Middle NameProvider Last Name *SuffixStreet AddressPlease enter the provider's Street Number and Street Name (or PO Box)Unit NumberCityStateZIP codeNational Provider Identifier Number (NPI)Provider Phone Number *Provider Fax NumberMedical 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. Submit
