VCC New Patient Form

VCC New Patient Form

Personal Information

Name*:
Address*:
E-Mail*:
Phone:


Doctor's Information

Please provide us with information related to the doctor that issued your current recommendation.

The information provided below may be used for verification purposes. By providing this information and submitting this form you authorize your doctor to release information regarding diagnosis and treatment.

Doctor's Name*:
Address*:
Phone*:


Required Documents

California DL/ID No.*:
Attach DL/ID*:
Doctor's Recommendation No.*:
Expiration*:
Attach Doctor's Rec.*:


Legal Requirements

The following section contains statements with which you must agree in order to participate in services as provided by Valas Collective Care (VCC). If you do not agree to any of the statements below, or if you have any questions regarding these legal requirements, please do not submit this form. Contact a VCC representative to discuss any questions or concerns.

  • I as an active member of VCC, I here designate the collective as my primary medical marijuana care-giver/provider on the basis I cannot produce it for myself, and understand and agree that VCC will be the only collective in which I authorize to cultivate, procure, or transport medical marijuana on my behalf. Pursuant to California state laws.
  • I agree to keep my medicine to myself, not to give, share, donate, sell and trade any medical marijuana I receive from VCC.
  • I agree to not operate any machinery or a motor vehicle while using medical marijuana.
  • I agree to follow the laws governing medical marijuana in California.
  • I have been informed to the healthcare services offered by VCC.
  • I agree to keep all information regarding VCC PRIVATE

I understand and agree as follows:

I am a qualified patient protected by California Health and Safety Code 11362.7. et. seg., and Senate Bill 420. My doctor has recommended the use of medical marijuana and provided written documentation of such recommendation. My doctor will review my case on a yearly basis. Per the relevant sections of California law, I am able to legally possess, use, and cultivate cannabis collectively for medical purposes. I designate Valas Collective Care as my care providers and give them the right to Cultivate for me as a member of Valas Collective Care. I agree to follow all the rules and guidelines for the collective and donate reasonable compensation and/or volunteer for other services and activities provided by the collective.

Full Legal Name: Date:


VCC Charge Authorization

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