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Get Arizona Medical Marijuana Certification Form

Rizona License Number: Type: MD DO NMD/ND MD(H)/DO(H) PHYSICIAN INFORMATION ON FILE WITH LICENSING BOARD Office Address: Telephone Number: Email Address: QUALIFYING PATIENT INFORMATION Patient’s Name: Date of Birth: CHECK ONE OR MORE BOXES TO INDICATE QUALIFYING PATIENT’S DEBILITATING MEDICAL CONDITION Acquired immune deficiency syndrome (AIDS) Agitation of Alzheimer's disease Amyotrophic lateral sclerosis (ALS) Cancer Crohn's disease Glaucoma Human immunodeficiency virus (H.

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