Renew Please complete this short form so we can assist you in renewing your Maine medical marijuana card. Choose All Medical Conditions That Apply to YouGeneral Conditions Severe Pain Nausea Muscle Spasms Seizures Cancer Inflammatory Bowel Disease Specific Conditions Cachexia Glaucoma HIV+/AIDS Agitation of Alzheimer's ALS Hepatitis C Nail-Patella Syndrome None I suffer from NONE of the above conditions You have indicated that none of the above conditions apply. However, this may not be true. Take a look through the detailed conditions below and make sure that none apply to you. Don't be afraid to check the "OTHER" box if you are just not sure. You have indicated that you are suffering from "Severe Pain". Please help us narrow down your condition by choosing a more specific item below. Don't be afraid to check the "OTHER" box if you are just not sure.Severe Pain Arthritis Chronic Pain Syndrome Colitis – Ulcerative Chronic Back Pain Degenerative Joint Disease (DJD) Degenerative Disc Disease (DDD) Fibromyalgia Gout GERD (Reflux) Herniated Disc Irritable Bowel Syndrome (IBS) Lumbar Stenosis Lumbago Lupus w/ Joint Involvement Migraine Headaches Neuropathy Plantar Fasciitits Ruptured Disc Radiculopathy Spinal Stenosis Spondylosis Spina Bifida Scoliosis Severe Peptic Ulcers Severe Joint Pain TMJ Trigeminal Neuralgia OTHER Severe Pain Condition Other Please Describe Your Exact Severe Pain Condition*You have indicated that you are suffering from "Nausea". Please help us narrow down your condition by choosing a more specific item below. Don't be afraid to check the "OTHER" box if you are just not sure.Nausea Chemotherapy Diverticulosis Irritable Bowel Syndrome (IBS) Medical Associated Nausea Meiner's Disease Nephropathy Peptic Ulcers Radiation Therapy Sprue Vertigo OTHER Nausea Condition Other Please Describe Your Exact Nausea Condition*You have indicated that you are suffering from "Muscle Spasms". Please help us narrow down your condition by choosing a more specific item below. Don't be afraid to check the "OTHER" box if you are just not sure.Muscle Spasms Chronic Back Pain Charcot-Marie-Tooth Disease Limb Trauma Movement Disorder Nocturnal Leg Cramps Parkinson’s Disease Multiple Sclerosis Restless Leg Syndrome Tourette’s Syndrome Spasticity Condition Dyskinetic and Spastic Movement Disorders OTHER Muscle Spasm Condition Other Please Describe Your Exact Muscle Spasm Condition*You have indicated that you are suffering from "Seizures". Please help us narrow down your condition by choosing a more specific item below. Don't be afraid to check the "OTHER" box if you are just not sure.Seizures Epilepsy OTHER Seizure Condition Other Please Describe Your Exact Seizure Condition*You have indicated that you are suffering from "Cancer". Please help us narrow down your condition by choosing a more specific item below.Cancer Bladder Breast Colon Rectal Endometrial Kidney Leukemia Lung Melanoma Non-Hodgkin Lymphoma Pancreatic Prostate Thyroid OTHER Type of Cancer Other Please Describe Your Exact Cancer Condition*Are you currently in possession of your medical records?*YesNoGreat! This will greatly speed up the process! Make sure to keep those handy and bring them with you to your appointment as they are required for getting approved for your card.Don't worry, we've got your covered! We can help you obtain your records very easily. You will be presented with a few options at the end of this form.Which location is most convenient for you?*PortlandBiddefordOtherContact InfoName* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Enter Email Confirm Email Zip Code*Phone*When is the best time to reach you?*Depending on which clinic you selected, it will be imperative that we speak to you to continue the process. Please contact me ASAP!11a - 1p1p - 3p3p - 5p5p - 7p7p+Now offering TeleMed service We now offer the option of seeing the doctor from the comfort of your home with our TeleMed service. The only requirement is that you have a mobile phone or computer equipped with a standard webcam. If so, you can take your appointment wherever you are, it's that simple. Please check the box below if you are interested.TeleMed? I AM interested in your TeleMed service I am interested in more information about... Weekly Newsletters Dispensaries New Product Information Volunteering Finding a Grower Growing for Other Patients My Medical Condition Participate in Clinical Trials NameThis field is for validation purposes and should be left unchanged.
