Verified Florida Patient Application | Green Street Vapor Co.

Patient Verification Process

STEP 1: REGISTER AN ACCOUNT — HERE. (IF YOU DON’T HAVE A USER ACCOUNT, WE CANT SET YOU AS A PATIENT.)

STEP 2: ONLY AFTER you finish Step 1…….THEN fill out, and submit the patient verification form below.

STEP 3: Attach a photo or scan of your patient I.D. (Please cover all personal information EXCEPT your Name, and Photo)

STEP 4: Submit your patient application.

Name
First Last
Email
D.O.B.
Date Format: MM slash DD slash YYYY
Patient I.D.*
Accepted file types: jpg, png, pdf, jpeg.
Please upload an image of your Registry Identification Card with your name visible. **For your safety, please block out any sensitive information.
Email Opt In
- Email Opt In
*Check above to opt in to receive notifications, special offers, and special invitations from Green Street Vapor. (You may opt out at any time)
Phone
This field is for validation purposes and should be left unchanged.