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Yellowstone Valley Herbs |
"Your Montana Medical Marijuana Program Services Provider". |
Patient Information Form Last Name:_____________________________________First Name:___________________________________M.I.:_________ Address:________________________________________________________City:______________________Zip:___________ Mailing Address:_________________________________________________City:______________________Zip:___________ Home Phone:______________________Cellular Phone:____________________Email:________________________________ Occupation:______________________________________________________Employer:_______________________________ Emergency Contact:___________________________________________________Phone:_______________________________ I am: A new patient____ An exsisting patient____ My qualifying medical conditon:_________________________________ Date of last medical exam/ registration renewal:______________________________/_________________________________ Medications I take and dosage:______________________________________________________________________________ Preferred MM application:__________________________________________________________________________________ I hereby authorize Yellowstone Valley Herbs and it's representatives to share information regarding my care with the following entity: Name:___________________________________________________________________________________________________ Address:_________________________________________________________________________________________________ Phone:_________________________Fax:__________________________Email:_______________________________________ Nature of Relationship:____________________________________________________________________________________ Signature:________________________________________________________________Date:___________________________ As a patient of Yellowstone Valley Herbs I agree to the following: I have read, understand and will abide by the laws of the state of Montana in regards to my conduct as a MMP participant. I will not share or resell the medication provided to me by Yellowstone Valley Herbs. I will not operate a vehicle or machinery while using the medication provided to me by Yellowstone Valley Herbs. I reserve the right to end the patient/ provider relationship with Yellowstone Valley Herbs at any time and will provide them with 30 days written notice of my intention to do so. Signature:________________________________________________________________Date:___________________________ As a patient of Yellowstone Valley Herbs I understand the following: Yellowstone Valley Herbs will follow all laws of the state of Montana in regards to being a MMP services provider. Yellowstone Valley Herbs will not share my information with anyone without prior written consent from me. Yellowstone Valley Herbs will not allow pick-up or delivery by or to anyone other than myself. Yellowstone Valley Herbs reserves the right to end the patient/ provider relationship with me at any time and will provide 30 days written notice of their intention to do so. Signature:________________________________________________________________Date:__________________________ |
Registration Number: __________________ Date Issued:_______/_______/________ |