Register Please use the form below to send us your recommendation information for verification. **Must be over 21 to order**18 and up with parental consent. Part I: Patient Information *First Name : *Middle Name : *Last Name : *Home Address : Address 2 (apt,suite, floor, etc.) : *City : *State : *Zip : *Date of Birth : (MM/DD/YYYY) *CA License or ID Number : *Expiration Date : (MM/DD/YYYY) *Email Address : Sign up for our FREE newsletter : YES! Sign me up! *Phone Number : (555-555-1212) *Referred by : Part II: Physician & Recommendation Info *Patient ID Number : *Physician's Name : *Physician's Address : *City : *State : *Zip : *Verification Website : *Physician's Phone Number : (555-555-1212) *Recommendation Expiration Date : (MM/DD/YYYY) Upload a photo or scan of your medical card or physician's recommendation : Maximum upload file size : 2147483647 bytesAcceptable file types : jpg, jpeg, tif, gif, png, pdf JPG, JPEG, TIF, GIF, PNG, or PDF only By clicking "Submit Verification": 1) I hereby authorize my treating Physician, as required by State and Federal Laws including HIPPA regulations, to release my medical information concerning my diagnosis, condition, and/or prescription to Crystal Paradise and its duly authorized representatives; and 2) I also agree to join and follow all rules associated with Crystal Paradise Collective, SB420 and Prop 215.