___ I am a Patient / ___ I am a Primary Caregiver for __________________________

First name_______________________Last name___________________________

Address___________________________________________________________

City________________State________________Zip________________

Calif. DL or ID Number __________ Date of birth____ / ____ / ____

State/County Medical Cannabis card number ______________________________

Recommendation issued by:_________________Exp. Date______ / ______ / ______

Phone number ( _____ ) _______________________

If you would like to receive periodic news and updates on medicines and services provided by Canto Diem, please provide your email address below

________________________________________________
Please note: Your address will NEVER be given to anyone else and you can unsubscribe at any time.

I have read and understand the Canto Diem building guidelines.

I consistently rely upon Canto Diem for my safety and well being as per California Health and Safety Code 11362.5.

I authorise my recommending Doctor to verify his/her recommendation or approval for the use of medical cannabis.

Signature___________________________________Date______ / ______ / ______