Shop Promotions Medical Program Info Contact Menu Shop Promotions Medical Program Info Contact keep me hidden me too Patient Registration Personal Inforamtion First and Last Name (As it appears on your ID) Date of Birth MMJ Registration Number (Must be 20 digits) MMJ ID Registration Expiration Date Drivers License or Passport # (whichever you registered with) State ID Expiration Date Current Address (Your address must match the address on your driver's license. If they differ, please update in the registry or provide verification of current address at your next visit.) City State Ohio Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code Gender Male Female Other Preferred Pronouns (Optional) Preferred Name (Optional) Phone Number Email Address Emergency Contact (Optional) Emergency Contact Name Phone Number Relationship to Patient Caregiver (Optional) Caregiver Name Phone Number Caregiver Registration ID Number Current Address City State Ohio Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code Other Information Status (Select any that apply) Indigent Status Veteran Status Terminally Ill Industry Employee Have you used cannabis before? Yes No If so, what is your experience with it? A few times in your life A few times a year A few times a month Weekly Daily What type of medical cannabis are you familiar with or interested in? Flower (Plant Material) Edibles Extracts Tinctures Topicals Do you have any allergies or are you prescribed any medication(s) that may cause adverse reactions to MMJ products that you would like for us to be aware of? Yes No Unsure How did you hear about us? Word of Mouth Leafly Social Media Walk by/Drive by Other Opt-in to ROAM Dispensary's Newsletter! Opt-in to receive communications from ROAM Dispensary By checking here, I attest to have read and agree to ROAM Dispensary's Patient Waiver of Liability and Hold Harmless Agreement. Please draw your signature below and press "Attach Signature" before submitting Clear Attach Signature Download Signature No Signature Attached Please attach your signature before submitting. Register Refund Policy [email protected]7781 Broadview Rd Seven Hills, OH 44131 Programmed, Designed, and Hosted by KawaConnect LLC © 2025 AB Retail LLC Instagram Terms of Service Privacy Policy DCC Approved Pesticides for use in Cultivation of Medical Marijuana in Ohio
