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Medical Marijuana Physician Certification  Form

Medical Marijuana Physician Certification Form

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S debilitating medical condition. I attest that the information provided in this written certification is true and correct. M E D I CA L M AR IJ U A N A P H YS I C I A N C E RT IF I CAT I O N PHYSICIAN INFORMATION FOR ALL QUALIFYING PATIENTS Physician s Name Arizona License Number Type MD DO NMD/ND MD H /DO H Office Address Telephone Number Email Address QUALIFYING PATIENT INFORMATION Patient s Name Date of Birth CHECK ONE OR MORE BOXES TO INDICATE QUALIFYING PATIENT S DEBILITATING MEDICAL...
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