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.

Are You A Registered Patient With The Commonwealth Of Virginia?*

  1. Yes

  2. No

Are You A Veteran?*

  1. Yes

  2. No

How Did You Find Us? (Check All That Apply)*

  1. Google

  2. Leafly

  3. Weedmaps

  4. Yelp

  5. Referral/Friend

  6. News Article

  7. Doctor’s Recommendation

  8. Others

NEW PATIENT REGISTRATION

Nearest RISE Dispensary*

Name*

Email*

Date Of Birth

Phone*

Address*

Patient ID No./Medical Marijuana Card No.*

Expiration Date*

Additional Notes (Optional)

0 of 500 max characters

Would You Like A Free Consultation With Our Patient Care Team?*

  1. Yes

  2. No

Do We Have Your Permission To Send Text Message Alerts?*

  1. Yes

  2. No

Packaging Preference*

  1. Child Resistant

  2. Easy Open

  3. No Preference

Please upload copies of the following:

Virginia ID

Accepted file types: jpg, pdf, png, Max. file size: 50 MB, Max. files: 1.

Registration Card

Accepted file types: jpg, pdf, png, Max. file size: 50 MB, Max. files: 1.

Letter Of Certification

Accepted file types: jpg, pdf, png, Max. file size: 50 MB, Max. files: 1.

Accepted file types: jpg, png
Maximum file size: 50 MB

Signature*

Date*

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