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Patient Forms

Patient Forms

Below are the required forms that you will need in order to obtain your Registry I.D card. If you are unable to download the listed forms please contact our office.

FOR VETERANS

For veterans that will need to request your DD214 and your VA Form 10-5345 you will need to fill out the Standard Form 180 (please click on our patients page to locate this form  Or contact our office at (312) 473 – 4002 and our office will mail you this document) If you are unable to obtain a SF-180, you may still submit a request for military records. Requests must contain enough information to allow the VA to identify your record.

Please include as much of the following information as possible:

  • The veteran’s complete name used while in service
  • Service number or social security number
  • Branch of service
  • Dates of service
  • Date and place of birth may also be helpful, especially if the service number is not known
  •  Place of discharge
  •  Last unit of assignment
  •  Place of entry into the service, if known.

You can return these completed documents via fax to: 314-801-9195 or by mail to the following address:

National Personnel Records Center
1 Archives Drive
St. Louis, MO 63138

Located near the bottom please place the following information:

Contact our office at (312) 473-4002 to speak with our Patient Advisors.

Medical Marijuana of Illinois

A Complete application must include the following:

  • A signed and completed application form.

  • Proof of residency

    (pay stub, valid Illinois drivers license or state ID, mortgage or rental/lease agreement)

  • Proof of identity of the qualifying patient

    (color photocopy of a U.S. or Illinois government issued photo ID)

  • Proof of age of the qualifying patient

    (color photocopy of a U.S. or Illinois government issued photo ID)

  • Photograph of the qualifying patient

    (Contact the Department’s Division of Medical Cannabis if a photograph would be in violation of or contradictory to the qualifying patient or designated caregiver’s religious convictions) - A photograph will be included with your Live Scan Fingerprint procedure.

  • Physician written certification

    or appropriate documentation for veterans receiving medical care at a U.S. Department of Veterans Affairs facility; your physician must mail in this form.

  • Designated caregiver information,

    if applicable.

  • Copy of the fingerprint consent form

    (this form can be located on our patient forms page)

  • Excluded offense waiver

    if applicable.

  • Selection of medical cannabis dispensary or zone

    (this confirms the county in which you reside)

  • Application fee.

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Medical Marijuana of Illinois.

All Rights Reserved. Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced in whole or in part in any manner.

Medical Marijuana of Illinois          Medical Marijuana of Illinois          Medical Marijuana of Illinois

“DISCLAIMER: Medical Marijuana of Illinois (MMI) solely acts as an intermediary between the product and patients. MedMarijuanaofIL.com does not directly engage in the selling or growing of medical marijuana. Medicinal Marijuana should only be used by patients holding a medical marijuana ID card.”

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