Age Gate
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WELCOME TO
RISE DISPENSARIES

It’s nothing personal,

WE GOTTA MAKE SURE YOU’RE 21+*

*For Pennsylvania, New York, Maryland and Minnesota you must be 18+

By clicking “YES” and entering the website, I agree to be bound by the Terms of Service, Privacy Policy and Notice of Privacy Practices.

Part 1 *Personal Info
Part 2Medical Cannabis History
Part 3 *Privacy Practices Notice
Part 4 *Code Of Conduct Agreement
Part 5 *Authorization

Thank You For Being Here!

We are honored you’ve chosen RISE as your medical cannabis provider. We look forward to getting to know you. Please tell us a little about you and your history with medical cannabis.

Full Name

Nickname

Medical Marijuana Card Number

Email*

Yes, I would like to receive information, community updates, and special offers. We promise we will not sell or share your contact information.
  1. Email

  2. Text

Select Dispensary*

Home Address

Mobile*

Home Phone

Occupation

Date Of Birth

Are You Facing Any Financial Hardships?

  1. Yes

  2. No

Are You A Senior

  1. Yes

  2. No

Are You A Veteran?

  1. Yes

  2. No

Caregiver Name (If Applicable)

Caregiver Phone No

Any Known Allergies?

Current Medications? (Prescription & Nutritional Supplements)

Name Of Medication

Dosage

Frequency

Anything Else You Would Like Us To Know About You?