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 bytes Acceptable 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.