Medical Marijuana Physician | Marquette, MI | Escanaba, MI | Houghton, MI | Iron Mountain, MI
                                                                                                                                                                                                                                                Copyright 2011.  MMMRC Clinics.  All Rights Reserved.
In order for a MMMRC physician to evaluate your case, you must register with us.  If you live near one of our clinics, we invite you to stop to register in-person at our clinic office locations.  If you don't
live close by, or have limited time, you may register online by using the form below.  

Patients who register online will receive an email, with instructions, detailing the next step in the process.  If you have any questions along the way, feel free to give us a call at (906) 228-2999, or send
email to inforequest@marquettemedicalmarijuana.com.  The form below is for in-clinic patients only.  
Name (Last, First, M.I.):
Address (street, city, state, zip):
Phone (i.e. (XXX) XXX-XXXX):
Mobile Phone: (i.e. (XXX) XXX-XXXX):
Email Address:
I am registering for the  (Choose Location) Clinic:
IMPORTANT:  You may register online, however, visits are by appointment only.  Payment is due at time of service.  NO
PERSONAL CHECKS.  There is no fee if your condition is not certified.  Medical Records and an appointment with our
board-certified physician(s) are required.
Referred By:
How did you learn about our clinic?
I Am...
Medical Records Available?
Date of Birth:
Name of Primary Doctor or Chiropractor:
Doctor's Phone (xxx) xxx-xxxx:
Please Describe Your Major Complaint (be
specific, detailed and include any/all diagnosis you
may have been given):
When Did This Condition Begin?
Does This Condition Interfere With (check all that
apply):
Work
Sleep
Daily Activities
Is This Condition Becoming Worse?
List Medications You Are Taking (including
over-the-counter)?
What other "conventional" treatments have you
and or your doctor tried for this condition?
Providing this information will help to get your case started, and will help MMMRC to learn a little bit more about your medical
condition.  Filling out this form DOES NOT guarantee your condition will be certified by your MMMRC physician.  Additional
documentation and information will be required.  

By clicking "Submit" below, I certify that the above information is correct to the best of my knowledge.  I will
not hold MMMRC physicians or staff responsible for any errors or omissions that I may have made in the
completion of this form.  I acknowledge that MMMRC Clinics, is not in any way undertaking responsibility
for my general healthcare, primary care, or providing any other treatments for my medical condition
specified in this form or other communication(s) with MMMRC.  In the event that I require additional medical
treatment for my medical condition(s), I understand that it is my responsibility to seek and acquire treatment
from my primary health care provider, emergency department, walk-in clinic, or other appropriate health
care provider that is not MMMRC Clinics.  I hereby certify that any and all medical records that I may
provide to MMMRC, are mine, and mine alone, and to the best of my knowledge have not been altered in any
way.  I also acknowledge that I have received a copy of MMMRC's Notice of Privacy Practices, and agree to
all the terms and conditions of MMMRC's Medical Marijuana Risks & Benefit's Statement and Patient
Acknowledgement Form for either new or renewal patients.
REGISTRATION FORM - (an MMMRC Representative will contact via phone to help you schedule your appointment time. Pre-registration is helpful not required.)
REGISTER TO BE OUR PATIENT
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