New Patient Intake Form Thank you for being here! Interested in becoming a Central Ave. Compassionate Care Patient? Simply fill out the form below and our team will be in touch within 24-48 hours with the next steps. Become a Patient Patient ID NumberDate of Birth MM slash DD slash YYYY Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneWork PhoneEmail Opt-In to Our Loyalty Program Yes! I want to receive sales, promotions and loyalty information via text & email.Are you an active, reserve, retired or disabled veteran?*Eligible veterans receive a 10% discount – ask your dispensing agent for details. Yes No How did you hear about us? Social Media Referring Physician A Friend Google Other If "Other" or "A Friend" Please List Here:Patient / Personal Caregiver Attestation I have received and read the Central Ave Compassionate Care, Inc. patient education materials. I understand that I must always carry my Program ID Card while I am in possession of, or transporting, marijuana for medical use, or at an RMD. I will not engage in the fraudulent use of my registration card. I understand that my registration only allows me to possess and use marijuana for medical purposes within Massachusetts. I understand that no one under the age of 18 is allowed in the RMD. Registered patients under the age of 18 have a licensed person caregiver to purchase medicine on their behalf. I understand that I may not distribute marijuana to any other individual, and must return unused, excess, or contaminated product(s) purchased at Central Ave Compassionate Care,Inc. to Central Ave Compassionate Care Inc. for disposal. PhoneThis field is for validation purposes and should be left unchanged.
