Conn- Contact and Appointment Form

B & B Medical Marijuana Evaluation Center of Connecticut

Contact 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 information about fees, process, etc. I have a general question
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Do you need Spanish speaking staff? *

Yes No

Screening Questions

Answer the two questions below, then 1) choose to send in limited information, or 2) take some time to submit forms
1) Have you been diagnosed by a medical practitioner (physician, nurse practitioner, psychologist, chiropractor, physical therapist) with a qualifying condition? Please refer to the list of medical conditions that qualify for a medical cannabis card in the state of CT? *

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 CT. Please fill out the attached form 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? *

I want you to reach out to me so you can help with the process I want to fill out forms and submit documents/IDs so I can get a head of the line

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 condition are you trying to get qualified with?
Do you also want to fill out a release form or other form?- You will likely need to fill out a release form so it is best to click yes *

Yes No
Would you like to submit ID and documents--You will have to eventually *

Yes No, I will do that later

Proof of Residency & Discount Required

Submit documents below, or ask us for help when we reach out
{name184}, Our office will require a few documents prior to your appointment to comply with Connecticut law. you may also email or fax our office with the documents if are not able to submit the records in the Upload Box below.

What you will need:

Proof of Connecticut 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 CT State agency Bank Statement or Utility Bill Lease or Title
Submit one of the 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/Husky Health
Submit Proof and/or Medical Records here

This Dropbox is Hipaa compliant
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Information Guide

Find out about our Fees & Process here
After reading the below information, would you like to complete our contact form? *

Yes No, I was just browsing

Submit your form below

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