Oakland Cannabis Buyers' Cooperative

This form needs to filled out in the OCBC offices.

Please do not print out and use this form you see below, it has been formated for web viewing only.

Exhibit E

Information Form

 

Name___________________________________________________

Street Address ___________________________Apt. Number______

City _____________________ State_________ Zip Code_________

Phone number (_______)__________________

Date of Birth ________________Gender (M or F)___________

Caregiver________________________________________________

Physician's Name ________________________________________________________

Address, City, State ______________________________________________________

Phone (______)_______________________________________

Specific Diagnosis ________________________________________________________

_________________________________ ICD9 CODE____________

Medication(s)_____________________________________________

________________________________________________________

How do you use cannabis? Smoke hi grade___
smoke lo grade___edibles___tinture__

Are you politically active?_______

___________________________________________
Member Signature

________________________
Date

___________________________________________
Member #

________________________
Intake By

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