Printable State Forms and Medical Release

Patient State Forms

For New and Renewing Patients to be submitted every two years

For New and Renewing children under 18- Must see 2 Doctors

PATIENTS use this form when adding or switching a Caregiver- you may also change your address with this form at the same time
* Only ONE address per registered patient or caregiver

Use this form if you need a new card!

This form is for patients who are removing current caregiver and will possess their own plants. You can also change your address with at this time. If new address is listed, state will update address on ALL active registry cars. Only one address per person in the program

For active CAREGIVERS who are removing one or more currents PATIENT(S). You can also update your address at this time. If the new address is listed, the state will update your address on all active registry cards.  

​Please Fax to 248-965-9104

Request replacement Card