Mon - Sat 12 - 7 | 1335 Lakeside Dr., Romeoville, IL 60446 630-359-3213

Patient Dispensary Registration

Save time during your first visit by filling out our patient information form below. To be eligible for expedited service, please complete at least 24 hours before your first visit.

Contact Information

State Identification

Please provide either a state issued identification number or your license number.

Patient Identification Info

  • Contact Info
  • State Info
  • Patient Info
  • About You

Contact Information

First Name

Last Name

Email Address

Street Address

Street Address (Line 2)

City

State

Zip Code

State Identification

Driver's license or alternative state identification number

Expiration Date

Birthday

Gender

Illinois Medical Cannabis Pilot Program Registration Info

Medical Cannabis Card Number

Expiration Date

Physician's Information

Provider's Name

Provider's Phone

Qualifying Conditions

About You

How did you hear about us

Do you have a caregiver?

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