PA Medical Certification – Herbal Haven Smoke Shop

Name

First

Middle

Last

Email

Phone Number

Last 4 of SSN

Driver's License #

*Must be a valid Pennsylvania license

Date of Birth – Month

Date of Birth – Day

Date of Birth – Year

Are you under 18?

I am under 18

Patients under 18 years of age requires parent / guardian permission

Parent / Guardian E-Signature (If patient is under 18)

Parent / Guardian Phone Number (If patient is under 18)

Street Address

City

State

Zip Code

Patient Status

New Patient
Re-Certification

Medical Conditions: (Click all that apply)

Acknowledgement of Safe Use of Medical Marijuana – Effects

I understand the effects of Medical Marijuana

I understand that side effects may occur while I am taking medical marijuana for example, euphoria, difficulty in completing tasks, low blood pressure, sedation, dysphoria, alterations in the perception of time and space, dizziness, anxiety, confusion, impairment to short term memory, inability to concentrate, suppression of the body’s immune system, increased, talkativeness, impairment of motor skills, delayed reaction time, loss of coordination, paranoia, and increased or decreased appetite. Also, smoking medical marijuana is illegal in Pennsylvania.

Acknowledgement of Safe Use of Medical Marijuana – Dependency

I understand I may become dependent on Medical Marijuana

I understand some patients may become dependent on marijuana, or experience withdrawal symptoms after cessation such as depression or irritability, insomnia, loss of appetite, trouble concentrating and fatigue.

Acknowledgement of Safe Use of Medical Marijuana – Mental Health History

I agree to tell the physician about my mental health history

I agree to tell the physician if have ever had symptoms of depression, psychosis, attempted suicide or other mental problems. I understand that marijuana may exacerbate schizophrenia or be harmful to a fetus.

Acknowledgement of Safe Use of Medical Marijuana – DUI

I understand I can still get a DUI under the influence of Medical Marijuana

I understand that I can get a DUI for driving under the influence of medical marijuana if impaired.

Acknowledgement of Safe Use of Medical Marijuana – Federal Law

I understand Medical Marijuana is still illegal under federal law

I understand that medical marijuana has not been approved under Federal Regulations and not been deemed legal under federal law. I understand that I must use my medicine within the privacy of my own home or have land or homeowner permission to use on property. I understand medical marijuana is for use only in Pennsylvania.

Acknowledgement of Safe Use of Medical Marijuana – Protections

I agree

I agree to follow up and understand that our offices are neither providing, dispensing nor encouraging any certain product for an underlying condition. I have read this document and declared that the information is understood and agreed to, AND holds the physician and his/her agents free of any responsibility for harm resulting from medical marijuana abuse.

Herbal Haven Employee Reference

This helps us at Herbal Haven!

Get Your Pennsylvania Medical Marijuana Card!

Fast and Easy!

Fill Out Form Below and Talk with Impact Recovery

Talk With the Certified Practitioner

Make Payment and Receive Your PAMMJ Card

New Patient or Re-certifications!

Discounted Prices!

Stress-free Process!

10% Off Every Purchase at any Herbal Haven Location!

Questions? Contact Impact Recovery!

(717) 607-6209

Pennsylvania Medical Marijuana Registration Form

Fill out the form below to register for your PA Medical Marijuana Card!

Impact Recovery will call you within 24 hours to help you take care of the rest!