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Registration
First name
Phone number
Last name
Date of birth
Email
Street Address
City
State
Postal / Zip code
Is this for a new 329 certification or renewal of an existing certification:
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Choose the qualifying illness to obtain a 329 card:
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I am receiving treatment for these conditions (or a chronic or debilitating disease/medical condition) and its treatment that produces one or more of the following:
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List your current medications (dosage and how often you take it):
List your primary care provider's name, address and phone number. Also list specialists you see regularly:
Do you consent to communicating with us via text message?
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