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NEW PATIENTS



Name *
Name
Phone *
Phone
CELL PHONE
Date OF BIRTH *
Date OF BIRTH
PLEASE SUPPLY YOUR DATE OF BIRTH
Address *
Address
WHAT ARE WE TREATING
DOCTOR? CURRENT AW PATIENT? AD? SOCIAL MEDIA? WEBSITE? GOOGLE SEARCH?
THE FLORIDA MEDICAL MARIJUANA REGISTRY REQUIRES ALL PATIENTS TO SUPPLY THEIR SOCIAL SECURITY NUMBER SO THEY CAN VERIFY YOUR IDENTITY, AMERICANN WELLNESS KNOWS THIS IS PROTECTED INFO AND YOU MAY INSTEAD WAIT TO SUPPLY THIS INFO AT YOUR FIRST APPOINTMENT WHEN YOU MEET YOUR PHYSICIAN.
PRIMARY CARE DOCTOR
PRIMARY CARE DOCTOR
FL RESIDENT ? *
ARE YOU A FLORIDA RESIDENT WITH A FLORIDA DRIVERS LICENSE OR FL GOVERNMENT ID CARD? ONLY FLORIDA RESIDENTS MAY APPLY, AND YES SEASONAL RESIDENCY IS ACCEPTABLE!
VETERAN *
WE HONOR OUR VETERANS! THAT IS WHY ALL VETERANS WILL RECEIVE 50% OFF UPON PROOF OF SERVICE, IT IS YOUR RESPONSIBILITY TO SUPPLY PROOF OF SERVICE AT YOUR APPOINTMENT BEFORE ANY DISCOUNT WILL BE APPLIED
LIVING ON DISABILITY? *
(IF YES, THEN AW MAY REQUEST ENROLLMENT VERIFICATION LETTER, AMERICANN WELLNESS DISABILITY HARDSHIP FINANCIAL HARDSHIP PROGRAM WILL NOT BE APPLIED UNTIL PROOF OF DISABILITY ENROLLMENT IS SUBMITTED. (HARDSHIPS ARE 50% OFF)
AMERICANN WELLNESS REQUIRES ALL NEW PATIENTS TO PUT DOWN PAYMENT INFO VIA CREDIT OR DEBIT PRIOR TO THE FIRST APPOINTMENT VISIT/ AN AMERICANN WELLNESS REPRESENTATIVE WILL BE IN CONTACT TO OBTAIN PAYMENT INFO
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NEW PATIENTS THAT ALREADY HAVE THEIR FLORIDA MEDICAL MARIJUANA CARD WILL NEED TO BE RELEASED FROM THEIR PREVIOUS DOCTORS REGISTRY.