Please read each item below and answer fully and truthfully. Please tell Dr. Kudler if you do not understand any of the information provided or any of the information being requested. You can use your mouse pointer or your finger to sign the signature boxes below. Do not sign this form and do not use Medical Marijuana if you have questions about or do not understand the information you have received or provided.

I do not certify adults younger than 21 for the medical use of cannabis.

Standard Fee: $100

Discounted Fee: $60 (with proof of MassHealth/SNAP/SSI/SSDI/Veteran status)

10% additional discount for colleagues in the cannabis industry, school teachers, and mental/behavioral health professionals —> $90/$55

I DO NOT PROVIDE ALLOTMENTS ABOVE THE DEFAULT OF 10 OUNCES PER 60 DAYS