GreenLantern Medical

Patient Verification

* Your Name:

* Date of Birth:

* Your Email

* Your Phone Number:

* California Drivers License #:

* Patient/Rec ID #

* Verification Website:

California State Medical Marijuana Card No.

* How did you hear about us?

* Print Name for Electronic Signature:

* Type the numbers.

* Zip Code:

After submitting the form above. Please submit the signed membership application via email or fax to 267-219-6669. For digital signatures, use this free utility.  Then submit/email your digitally signed membership agreement. Our drivers also carry membership agreements to sign upon delivery if you’re unable to submit electronically.

Please be prepared to present your Doctor’s recommendation upon delivery