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 have I want to see information about fees, process, etc. I have a general question
Name *

First Name Last 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? *

Yes No

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? *

Yes No
2) Can you provide medical records documenting this medical condition? *

Yes No
*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 documents Submit 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 Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Date of Birth *

Month Day Year
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 *

Yes No
You will need to submit ID and other Documents for proof of residency or a discount. *

I want to submit documents now I 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 ID Car insurance or registration Any communication from a MA State agency Bank Statement or Utility Bill Lease or Title
Submit one of the following for Proof of Discount.

SSI/SSDI Award Letter Benefit Verification Letter (if you were disabled, but you are now over 65) VA status/disability benefits Medicaid/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 form I want your office to reach out to me before filling out anything No, 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

B & B Medical Marijuana Evaluation Center of Massachusetts