Questionnaire Widget

MELBOURNE PATIENT TRANSFER FORM

First Name *

Last Name *

Gender *

Male Female

Phone Type *

Mobile Landline

Email *

Phone *

Driver's License Number *

Date of Birth *

Residential Address *

City *

State *

County *

ZIP Code *

Referred By

Contact Options
Email SMS

MMU Patient # *

Preferred Language? *

English

Spanish

Care Taker Detail

Full Name *

Email *

Date of Birth *

Driver's License Number *

Social Security No. *

Phone No. *

Address *

Certification for Medical Marijuana (Minor Patient must have second opinion letter and medical records.)

Prescribed medication Medical records with a qualifying diagnoses Second opinion letter (A second opinion letter from a Medical doctor who is a MD or DO that will state that the benefits of Medical Marijuana will likely outweigh the risks)

You acknowledge that you will provide the state required documentation for your minor child.

Transfer Patient option is for established Florida patients who are already registered with the state.