Submit Your Patient ID Number

For us to complete your electronic certification process with the State of Pennsylvania, simply complete the form below. After your information has been submitted you will receive a confirmation email. The State will provide you with the next steps on how to process your Medical Marijuana card via email. Please allow approximately two weeks before the State will notify you after the form has been submitted

Name*
First Last
Appointment Date*
MM slash DD slash YYYY
Choose the Office You Visited
Email*
Phone*
Date of Birth*
Month
Day
Year
4-6 Digit Patient ID Number*
Please enter a number from 999 to 999999.