1

General

2

Upload

3

Questions

4

Agree

Info

Enter some general information about yourself.

Upload

Upload your Drivers License and Medical Marijuana Card. Please take one picture per identification card and ensure that all text is legible. Drivers License and MMJ card must both be valid.
Upload your drivers license.
Upload License
Upload your MMJ Card.
Upload MMJ Card

Questions

Agree

HIPAA NOTICE OF PRIVACY PRACTICES

Although the provision of Medical Cannabis pursuant to Arizona state law is not governed by the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), Herb’N is committed to your privacy. OUR COMMITMENT TO YOUR PRIVACY We are dedicated to maintaining the privacy of your health information and patient records, and we will maintain the confidentiality of your health information and patient records.

TERMS AND CONDITIONS

I hereby state that as a qualified patient who has received a valid physician’s recommendation for the use of medical cannabis pursuant to the Arizona Medical Marijuana Act (AZMMA). I understand that it is a direct violation of HIPPA regulations as well as ANS Policy to make any audio or video of any kind upon or within the dispensary and I further agree not to make any such recording. I agree to abide by the terms and conditions as set forth in this agreement and abide by all dispensary rules.
1. I hereby declare under the penalty of perjury under the laws of the State of Arizona that a medical doctor recommended or approved my use of cannabis and that I have received a valid Patient Card through the Arizona Department of Health. I will remain in compliance with all applicable state and local laws.

I Agree
2. I hereby verify that I am a resident of the State of Arizona and my medical cannabis will not be taken out of the state of Arizona. I will keep medication contained and sealed while on premises. I further verify and agree that my medical cannabis shall not be shared, sold, bartered, traded, exchanged, or delivered by any means to any other person for medical or other reasons. I understand that diversion of medical cannabis for non-medical purposes and/or to other individuals shall be grounds for immediate termination of this agreement. I also agree to request amounts of medical cannabis strictly for my personal use at reasonable necessary intervals

I Agree
3. I understand and agree that while medical cannabis has been authorized by the State of Arizona, the Federal Government may persist in enforcing portions of the Controlled Substances Act which makes the possession and use of medical cannabis a federal crime. I certify that I am aware that possession and use of cannabis for medical purposes might be grounds for prosecution under federal law. Herb’N accepts no responsibility for any transgressions by the patients

I Agree

GENERAL RELEASE, INDEMNIFICATION, AND HOLD HARMLESS CAUSE:

I , being of lawful age and sound mind do now release, acquit, and forever discharge Greens Goddess Products, Inc. dba Herb’N from all actions, claims, demands or damages accruing to me resulting from any known or unknown injury, loss or damage sustained by or to me or from any injury caused by me while under the influence of this medicine. This release shall remain in force for any known and unknown alleged damages. I further agree to indemnify and hold Greens Goddess Products, Inc. dba Herb’N and the individual employees harmless for any injuries and/or damages resulting from use or misuse of medical cannabis obtained from the dispensary.