Get Registered with Crystal Paradise Medicinal Cannabis, Medical Marijuana Delivery, East Bay, Oakland, Alameda, Berkeley

**Must be over 21 to order**
18 and up with parental consent.

Please use the form below to send us your recommendation information for verification.

I. PATIENT INFORMATION

First Name:
Middle Name:
Last Name:
Home Address:
Address 2:
(apt, suite, floor, etc.)
City:
State:
Zip:
Date of Birth:
CA License or ID No.:
Exp. Date:
Email Address:
Sign up for our FREE
newsletter:
Phone:
Referred by:

*
*
*
*
*
*
*
(MM/DD/YYYY) *
*
(MM/DD/YYYY) *
*
YES! Sign me up!
(555-555-1212) *
*

II. PHYSICIAN & RECOMMENDATION INFO

Patient ID Number:
Physician's Name:
Physician's Address:
City:
State:
Zip:
Verification Email:
Physician's Phone:
Rec. Exp. Date:

*
*
*
*
*
*
*
(555-555-1212) *
(MM/DD/YYYY) *

By clicking "Submit Verification": 1) I hereby authorize my treating Physician, as required by State and Federal Laws including HIPPA regulations, to release my medical information concerning my diagnosis, condition, and/or prescription to Crystal Paradise and its duly authorized representatives; and 2) I also agree to join and follow all rules associated with Crystal Paradise Collective, SB420 and Prop 215.