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Greenleaf Clinics
Renewal California

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Returning Patient Form

Returning Patient Form

When you submit this form, your information will be sent via our secure server. Special notice.

Please fill out our on-line patient renewal form. This form is for our California patients who want to renew
thier 12 month medical cannabis recommendation.


This renewal is for returning Greenleaf Care patients only.

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Returning Patient Form

All patient information is completely confidential.
We are HIPAA compliant and protect patient privacy at all times.

↓ Greenleaf Care Patient Information

  ( * Required )

  1. Your patient ID is required.Exceeded maximum number of characters.Minimum number of characters not met.

  2. Your Greenleaf Care Physician's name is required.


    3. ↓ Patient Information


  3. Your name is required.

    6. ↓ Mailing Address

    (*Note)

    Your recommendation will be mailed to the address below.


  6. Your street address is required.

  7. Your city is required.

  8. Your zip code is required.

  9. Valid Email Please.Invalid format. Exceeded maximum number of characters.

  10. Your Email does not match. Please re-enter.Email does not match. Please re-enter.

  11. A valid phone number is required.Type numbers only with no spaces. Start with area code.

  12. Your Email does not match. Please re-enter.The values don't match.

    13. ↓ Medical History


    Please note!

    In order to for us to process your renewal request all questions must be answered below.


  13. YES  NO

  14. ↓ Primary Care Physician


  15. YES   NO

  16. ↓ Hospitalization


  17. YES   NO

  18. ↓ Specialist Evaluation


  19. YES  NO

  20. ↓ New Medications


  21. YES  NO

  22. ↓ Habits


  23. YES   NO

  24. ↓ Diagnosis


  25. YES  NO

  27. ↓ Frequency of Use


    30. ↓ Symptom relief


  30. YES  NO

  31. ↓ Credit Card Information

    Major Credit Cards Accepted

    "For your security we never keep your billing information on file."



  33. A value is required.



  34. /


    35. ↓ Credit Card Billing Address


  35. A value is required.

  36. A value is required.

  37. A value is required.


  38. { Your card will be charged a one time fee of $75.00 }


    Only click submit button once.

    The form may take a few seconds to process. You will be directed to a success page.

    * If form does not send please check to see if all required fields above are filled out. Thank you.

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Legal

GoDaddy.com SSL certificates support both industry-standard 128-bit (used by banks to safeguard sensitive data) and high-grade 256-bit SSL encryption to protect online transactions.

 

This SSL Certificate protects information flowing to and from our site and your computer from cyber thieves intent on stealing personal data. Names, addresses, passwords, account and credit card numbers – all are safe with our SSL.

 

This SSL certificate also guarantees that the Certificate holder Greenleaf Care, is who it claims to be and has a legal right to use the domain from which it operates.

IMPORTANT NOTICE: This renewal form is for our current Greenleaf Care patients only.


O.K.



If you are a new patient please fill out our New Patient Pre-Qualification form by clicking here.