Delaware Medical Marijuana Program
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There is a $20.00 application fee for the Visiting Patient ID card. Please make payment prior to submitting application or application will not be accepted. The Visiting Patient ID will have the same expiration date as your current state issued medical marijuana ID card

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Visiting Patient Application


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Dispensary Location
Delaware Dispensary Name
Delaware Dispensary City
Visiting Patient Information
First Name
Last Name
 
Date of Birth
(Must be 18 or Older)

Gender
At least one option should be filled
 Male      Female      X

Street Name
City

State
ZIP Code

State Certified for Medical Cannabis

Primary Phone
Email Address
Identification
Driver's License/State ID Number
Upload a copy of your current state Drivers License or ID
Medical Marijuana Card Expiration Date
Medical Marijuana Card
Upload a copy of your current Medical Marijuana Card
Patient's Attestation Statement
By signing below, the Patient certifies that the information on this application is complete, true, and submitted for the purpose of obtaining a State of Delaware Medical Marijuana Compassionate Use Patient Registry Card. If approved for the Registry Card, the Patient acknowledges receipt of and agrees to the terms of the Delaware Medical Marijuana Act, Title 16 of the Delaware Code, Chapter 49A.

I understand that completing the signature block electronically constitutes a legal signature confirming that I acknowledge and agree to the above statement
 
Patient's Signature
Payment
Application Fee Amount
$
Application Fee payed
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