New Patient Registration - Mayflower Boston

New Patient Registration - Mayflower

Please complete the form below to register for our Mayflower medical cannabis dispensary in Boston, MA.
Patient Name: *

First NameMiddle NameLast Name
Preferred Name/Pronouns
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Contact Phone Number*
Please enter a valid phone number.
What type of phone number is this?*

MobileHomeWork
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If Mayflower needs to contact you for patient-related reasons, what is your preferred way to receive communications?

EmailTextPhone
MMJ Card Number *
Expiration Date*

MonthDayYear
Date
Please upload an image of your MMJ card *

Cancelof
Type of Valid ID (License, Passport, etc.)*
ID #:*
Expiration Date*

MonthDayYear
Date
Please upload an image of the FRONT of your ID*

Cancelof
Do you qualify for any of the following? Mayflower offers various types of discounts, each with different criteria defining their eligibility. You will be asked to provide documentation.*

Senior (62+)TeacherVeteranStudentFinancial HardshipNone of the above
Please upload identification for above discount application.

Acceptable forms of documentation include:· Teachers: School district-issued staff ID cards; · Veterans: Verify prior military service (current service members are ineligible) using US Department of Defense-issued Common Access Card (military ID), Veteran ID card, Veteran Health ID card, Veteran’s designation on state-issued driver's license or military separation documents (e.g. DD Form 214).
Cancelof
How did you hear about Mayflower?*

Google or other web browserLeaflyWeedmapsSocial mediaPatient referralHealth providerOther
How would you like to receive marketing communications from Mayflower regarding promotions, new products, events, closing and other updates? Check all that apply.*

EmailTextI do not want marketing comunications
By providing your mobile number and signing the below field, you consent to receive marketing and advertising text messages and calls, including via an automatic telephone dialing system or prerecorded or artificial voice from Mayflower, its affiliates, and/or service providers. Consent is not required as a condition of purchasing any goods or services. Message and data rates may apply. Opt-out at any time by replying “STOP”.*

I understand
Phone Number for Text Marketing Communications*
Please enter a valid phone number.
Signature for Marketing and Advertising Text Communications*

Clear
Please select the ethnic background with which you most closely identify.*

AsianHispanic/LatinoWhite/CaucasianBlack/African AmericanNative Hawaiian/Pacific IslanderAmerican Indian/Alaska NativeI prefer not to answer
Please select your gender.*

MaleFemalePrefer not to answer
MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT

Please initial the statement below.
I understand that it is unlawful to use and possess medical marijuana outside of the State of Massachusetts. I understand that my registration card does not allow me to cultivate marijuana for any purpose unless I have applied for and received a Hardship Cultivation License. I agree that I will not divert any marijuana to any other person. All medical marijuana I purchase will be for my sole consumption. I agree that I will bring any unwanted or unconsumed marijuana to a Registered Marijuana Dispensary for disposal. I acknowledge that I can access to the Mayflower Medicinals' Patient Education Guide. by downloading it from www.mayflowermedicinals.com or obtaining it in store. I understand that marijuana has not been analyzed or approved by the FDA and that medical cannabis may contain unknown quantities of active ingredients, impurities or contaminants. I understand that the efficacy and potency of cannabis may vary widely depending on the cannabis strain and ingestion method. I understand that marijuana consumption during pregnancy and breastfeeding may pose potential harms. I understand that driving under the influence of Marijuana is prohibited by M.G.L c. 90, s. 24, and machinery should not be operated. I agree to not bring a weapon, or anything that can be used as a weapon to a Mayflower Medicinals, Inc facility. I agree to abide by Massachusetts Law in regard to my use of medical marijuana, and hereby release and waive all claims against Mayflower Medicinals from any and all liability related to my use of medical marijuana. Please input your initials *
Please do not sign this agreement if you do not understand the information you have received or are not comfortable with the risks that may be related to the medical use of cannabis or possession.
Patient Name: *

First NameLast Name
Patient Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

New Patient Registration - Mayflower

MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT