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 F

Authorization for Release of Patient Status

 

I, ___________________, hereby authorize my treating physician,

Dr. _________________, to release my current patient status to the Oakland Cannabis Buyers' Cooperative.

Member/ patient signature ___________________
Date _______________

Membership number _________