Forms

If you would like to fill out your patient forms ahead of time, please print the appropriate packet:

Certification & Renewal Packets

Miscellaneous forms

Application Use this form to apply for the Michigan Medical Marijuana Program.

Pain Log Track your pain or other symptoms with two entries per day for two weeks.

Patient Change Form This form should be used by patients to submit a legal name change, change of address, remove/add/change a caregiver or to request a replacement card.

Caregiver Change Form This form should be used by caregivers to submit a legal name change, change of address or to request a replacement caregiver card.

Medical Records Release Form This gives us permission to obtain your medical records. Please fill out and return to us with your doctor's phone number. If you prefer to sign the release form online, please call the office to request an electronic medical release for to be sent to you via email. If you already have your medical records, you may fax them to (269) 382-1197, or mail them to: Michigan Holistic Health, 500 Crosstown Pkwy, Kalamazoo, MI 49008.