Get Your Medicinal Cannabis Card.

Cannabis Clinic Card Application Form

Fill in the form below and provide the following information to successfully apply for your Medicinal Cannabis Card.

Please note that the card costs $25, which includes administration set-up cost & a year of validity.

Patient's Personal Information
Patient's Full Name*
First Last
Patient's Address*
Street Address Address Line 2 City ZIP / Postal Code
Email Address*
Patient's Date of birth*
Patient's Gender*
Mobile Number*
NHI Number
Medicinal Cannabis Product (prescribed)*
- CBD
- THC
- CBD & THC
Patient Identification
Patient's Valid Photo ID*
Valid form of ID such as a passport or a driver's license
Max. file size: 25 MB.
Patient's Full-face selfie*
A clear, full-face selfie with a white background
Max. file size: 25 MB.
Patient's Consent & Declaration
Patient's Consent*
- I agree that I am a patient of Cannabis Clinic
- I agree and acknowledge that I have a valid prescription from Cannabis Clinic as a patient
- I have read and agree to the privacy policy and consent to my personal data being stored and processed.
- I agree that the Medicinal Card will only provide me with identification and confirmation that I am a patient under the care of the Cannabis Clinic
Patient's Declaration*
To the best of my knowledge, the information that I have supplied is complete and correct.
First Last
Medicinal Cannabis User Card Application fee*
Price:
Phone
This field is for validation purposes and should be left unchanged.