Switch to FloraMedex

Fill out this form to switch your current dispensary to FloraMedex.

Submit the correct info and we'll take care of it.
 

PATIENT REGISTRY IDENTIFICATION NUMBER

First Name
Address
City
Zip

Last Name
Address 2
State
Phone Number
Email
Date of Birth

BY CHECKING THIS BOX, I HEREBY GIVE FLORAMEDEX PERMISSION TO SUBMIT A MEDICAL CANNABIS SELECTION FORM TO THE STATE OF ILLINOIS ON MY BEHALF.
Yes, I Grant Permission.