Maryland Patient Dispensary Registration

Save time during your first visit by filling out our patient information form below. To be eligible for expedited service, please complete at least 24 hours before your first visit.

Contact Information

State Identification

Please provide either a state issued identification number or your license number.

Patient Identification Info

  • Contact Info
  • State Info
  • Patient Info
  • About You

Contact Information

First Name

Last Name

Email Address

Phone Number

Street Address

Street Address (Line 2)

City

State

ZIP Code

State Identification

Driver's license or alternative state identification number

Expiration Date

Birthday

Gender

Special Designation

Maryland Medical Cannabis Commission Registration Info

Certification Number

Patient ID Number

Qualification Date

Expiration Date

Physician's Information

Provider's Name

Provider's Phone

Provider ID Number

Qualifying Conditions

Other

About You

How did you hear about us

Do you have a caregiver?