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.

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.