Patient Registration Patient Type* PatientCaregiverRenewal How did you hear about us?* YelpLeaflyGoogled ItInstagramFriendDr. ReferralOther First Name* Last Name* Date of Birth* California Drivers License/State ID #* Phone # Address City State Zip* E-mail Address* Dr. Name* Dr. License#* Recommendation Expires Your Recommendation ID #* Verification Website* I hereby authorize my treating doctor to release medical information regarding my diagnosis and condition to Balance MMC, Inc. I understand and agree as follows:I am a qualified patient protected by California Health and Safety Code 11362.7. et. seg., and Senate Bill 420. My doctor has recommended the use of medical marijuana and provided written documentation of such recommendation. My doctor will review my case on a yearly basis. Per the relevant sections of California law, I am able to legally possess, use, and cultivate cannabis collectively for medical purposes. I designate Balance MMC, Inc. as my care providers. I agree to follow all the rules and guidelines of the collective and pay reasonable compensation and/or volunteer for other services and activities provided by the collective. Signature* Having trouble? No problem, just give us a call! 619-598-4217.