Patient Registration

Tip: Before you begin filling out this form be sure to have your medical marijuana card and certification with you.
PLEASE NOTE: WE ARE UNABLE TO DELIVER TO ANY PO BOXES. TO LEARN MORE PLEASE CALL 844-484-7366 OR EMAIL PATIENTS@VIREOHEALTH.COM.
Medical Marijuana Registry ID Card Number -
Please enter ID number of your Medical Marijuana Program Registry Identification Card
NY Temporary Medical Marijuana Card ID Number -
Please enter ID number of your Medical Marijuana Program Registry Identification Card
NY Patient Certification (1 page) -
Please upload a scanned image or picture of the signed patient certification from your physician

If you have a caregiver, please provide us with the caregiver's name in the bottom box of this form.

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