• Be./Citiva New Patient Registration

    Please complete the form below. This will register you for all of our NY dispensary locations.
  • Patient Information

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  • Forms of Program Identification

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  • Qualifying Information

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  • A Designated Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary. If you feel that you need a caregiver, please contact your certifying physician. YOu will have the opportunity to complete contact information for your Designated Caregiver at the end of this form.


  • By providing your mobile number and signing and submitting this form, you consent to receive recurring informational, marketing and advertising text messages and calls at the number you have provided, including via an automatic telephone dialing system or prerecorded or artificial voice from Citiva, 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”.

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  • Designated Caregiver Information (if applicable)

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  • MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT

  • 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.

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