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NY State Medical Marijuana Card Application

New patient application

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Describe your medical condition

ALS

Cancer

Chronic pain

Epilepsy

HIV/AIDS

Huntington's

List your medications

Anything else you would like us to know?

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