Forms
If you would like to fill out your patient forms ahead of time, please print the appropriate packet:
Certification & Renewal Packets
- Patients new to marijuana program
- Renewal patients new to our clinic
- Renewal patients we have seen before
- Annual office visit
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.
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.
Change Forms
Add or Change a Caregiver Form This form is for active registered PATIENTS who are adding or changing their caregiver
Remove a Caregiver Form This form is for active registered PATIENTS who are removing their current caregiver and will possess their own plants.
Remove a Patient Form This form is for active registered CAREGIVERS who are removing one or more current PATIENT(S).
Replace a Lost or Stolen Card This form is for registered PATIENTS and registered CAREGIVERS who need to replace a registry identification card that was lost or stolen.
Change Name or Address Form This form is for registered PATIENTS and registered CAREGIVERS who need to update their registry identification card(s) to reflect a legal name change or address change.
Change Plant Possession This form is for active registered PATIENTS who are changing the plant possession and have an ACTIVE Caregiver.
Program WithdrawalThis Form is used to withdraw from the MMP.
LARA Release For Disclosure of Print Audit Number This form is used to receive your Print Audit Number (PAN) found on your registry card and used to link your previous account information online. The form must be signed and notarized within 90 days of submission and include proof of identity from the person authorizing the release of their PAN.
LARA MMP Release of Information This Form is used to receive your information from LARA MMP. All Release for Disclosure of Information forms must be signed and notarized within 90 days of submission and include proof of identity from the person authorizing the release of information. You must provide a signed and notarized authorization for each individuals’ information being released. Otherwise, that information will be redacted.