The pharmacists and staff at Southern CT Wellness & Healing are committed to providing the highest level of service to help guide our patients and their caregivers through the landscape of obtaining, prescribing, and using medical marijuana for palliative care. We provide a caring and comforting environment where we listen to your unique needs and administer holistic, alternative therapies to help you heal and achieve balance between mind, body, and spirit.
New Patient Form
Please open interactive PDF below. Once the form is complete you can do two things: save/print and bring it into SCWH on your initial appointment, or you may save/email to SCWH, and we will have it for your initial appointment.
Forms
Change of caregiver / Legal guardian form: http://www.ct.gov/dcp/lib/dcp/drug_control/mmp/pdf/changeofcaregiver-guardian.pdf
Change of Record form: http://www.ct.gov/dcp/lib/dcp/drug_control/mmp/pdf/changeofrecords.pdf
Report of Lost, Stolen or Damaged Certificate form: http://www.ct.gov/dcp/lib/dcp/drug_control/mmp/pdf/reportlostcard.pdf
Renewal of MMP Certificate
All patients must be RECERTIFIED by his/her physician every year prior to the expiration date.
The date of your card’s expiration will be on the front of your card.
Before your card expires, the registration system, https://www.biznet.ct.gov/dcp-mmrp , will allow you and your doctor to begin the renewal process.
The following is what each person will need to do to complete the renewal:
Physician:
- Confirm that the patient is under your care;
- Provide the date that you examined the patient for the renewed certification;
- Confirm that you still have a bona-fide patient/physician relationship;
- Complete the three certifications that are at the end of the form; and
- Update any other information to the extent it has changed from the previous year
Southern CT Wellness & Healing can help you with your renewal process.
Stop by our dispensary, call us at 203.496.5200
or email us at [email protected]
Patient:
- Provide proof that you still live in Connecticut;
- Provide an updated photograph;
- Complete the five certifications at the end;
- Pay a one hundred ($100.00) dollars registration fee; and
- Update any information to the extent it has changed from the previous year
- Remember: Only your physician can update your personal information. Before submitting your renewal, you will need to contact him or her if that information is no longer correct.
- If your name has changed, in addition to making sure your physician updates that information in his or her certification, you will need to provide the Department with proof of identity as you did for your initial registration.
Caregiver:
- Provide an updated photograph;
- Complete the five certifications at the end of the form; and
- Pay a twenty-five ($25.00) dollar the registration fee.