Mass- Contact and Appointment Form

B & B Medical Marijuana Evaluation Center of Massachusetts

Contact & Appointment form
What can we help you with?

I need an initial medical marijuana card, or I need to renew the card I already haveI want to see information about fees, process, etc.I have a general question
Name*

First NameLast Name
Email*
Please submit an email so that we can respond to your questions promptly.
Phone Number*
Please enter a valid phone number.
Do you need spanish speaking staff?*

YesNo

Screening Questions

Answer the two questions below, then decide if you want to 1. submit this contact form now with limited information, or 2. Continue filling out fomrs that you will be required to fill out later.
1) Have you been diagnosed by a medical practitioner (physician, nurse practitioner, psychologist, chiropractor, physical therapist) with a medical condition that the use of medical cannibas may help treat?*

YesNo
2) Can you provide medical records documenting this medical condition?*

YesNo
*If the answer to both questions is yes you may qualify for a medical card in MA. Please fill out the attached forms to contact our office.
Would you like to fill out forms and submit documents you will need later, or submit this information now and have us reach out to you?*

Fill out forms & submit documentsSubmit this & wait for us to reach out

Skip the line to get your initial medical card or renew your existing one

Complete the following steps online to get faster service
Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Email
example@example.com
Phone Number
Please enter a valid phone number.
What qualifying condition are you diagnosed with?
Select one
Do you also want to fill out a release form?--You may need to fill out a release form before your appointment, so it is always best to say yes*

YesNo
You will need to submit ID and other Documents for proof of residency or a discount.*

I want to submit documents nowI will submit documents later

Documents we need from new patients to our office

You may also upload medical records here if you have them on hand
Our office will require some documents prior to your appointment to remain compliant with state law.

What you need to submit:

Proof of Residency

Proof of Discounted Status
Submit one of the following documents to prove residency:

Driver’s license or state IDCar insurance or registrationAny communication from a MA State agencyBank Statement or Utility BillLease or Title
Submit one of the following for Proof of Discount.

SSI/SSDI Award LetterBenefit Verification Letter (if you were disabled, but you are now over 65)VA status/disability benefitsMedicaid/Masshealth
Submit Proof and/or Medical Records here

This Dropbox is Hipaa compliant
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Information Guide
After reading the below information, would you like to start the process?*

Yes, I want to start the process by filling out your contact formI want your office to reach out to me before filling out anythingNo, I am just checking out your information

Fees
New Patient: $145

New Patient Discounted: $135

Renewal Patient: $100

Contact Info
Phone: 833-739-0607

Fax: 401-921-5829

Email: info@bandbconsultingma.com

Submit your form below

We will reach out to you as quickly as possible
Comments/Concerns
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B & B Medical Marijuana Evaluation Center of Massachusetts