Patient Verification

PATIENT PRE-VERIFICATION

To Pre-Verify medical marijuana recommendations with Emerald Perspectives,
certified medical marijuana patients must completely and accurately fill out the form below.
Please have your recommendation and driver's license available to upload (ie: take a photo, scan it in, etc).

BE SURE TO HIT BOTH SUBMIT BUTTONS!!! THE BOTTOM ONE ONLY SUBMITS THE AGREEMENT, BE SURE TO SUBMIT ID/REC TOO!!!

Please complete the form below

* Indicates required field

Name *

First

Last

Phone Number *

Would you like to receive text messages? *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

CA Driver's License # *

Please upload a photo/copy of your CA Driver's License or photo ID. *

Max file size: 20MB

Please upload a photo/copy of your valid CA Doctor's recommendation *

Max file size: 20MB

How did you hear about us? If patient referral, please list their name. *

Submit

please read the patient member terms & conditions below
fill out the date & name sections
*click on the button to agree to the terms & conditions

Did you click the first submit button? Scroll up to check; if your info is still there, click "submit"

**you may also print out the Patient Member Terms & Conditions, sign them, and hand them in with your order.

PATIENT PRE-VERIFICATION

Please complete the form below

please read the patient member terms & conditions below
fill out the date & name sections
*click on the button to agree to the terms & conditions

Emerald Perspective Cooperative Inc.

Support

PATIENT PRE-VERIFICATION

Please complete the form below

*please read the patient member terms & conditions below​*fill out the date & name sections*click on the button to agree to the terms & conditions

Emerald Perspective Cooperative Inc.

Support

please read the patient member terms & conditions below
fill out the date & name sections
*click on the button to agree to the terms & conditions