"Medical Cannabis Dispensary Selection Form" - Illinois

This fillable "Medical Cannabis Dispensary Selection Form" is a document issued by the Illinois Department of Public Health specifically for Illinois residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

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Download "Medical Cannabis Dispensary Selection Form" - Illinois

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Medical Cannabis Dispensary Selection
Complete the following information and email to DPH.ChangeDispensary@Illinois.gov, fax to
217-782-1321, or mail to:
Illinois Department of Public Health
Division of Medical Cannabis
535 W. Jefferson Street; MC-002
Springfield, IL 62761-0001
Select One:
 This is the first time I am selecting a medical cannabis dispensary
 I am requesting a change in my medical cannabis dispensary
Name
Date of Birth
Patient Registry
QP.
Identification Number
EMAIL
Phone Number
Address
City
Name and Address of
Dispensary
Dispensary District
The Medical Cannabis Program will confirm your dispensary selection once it is processed.
You do not need to select a medical cannabis dispensary at this time. However, you must select a
dispensary in order to purchase medical cannabis. The list of dispensaries currently licensed with the
state of Illinois can be viewed at
http://www.idfpr.com/Forms/MC/ListofLicensedDispensaries.pdf
Medical Cannabis Dispensary Selection
Complete the following information and email to DPH.ChangeDispensary@Illinois.gov, fax to
217-782-1321, or mail to:
Illinois Department of Public Health
Division of Medical Cannabis
535 W. Jefferson Street; MC-002
Springfield, IL 62761-0001
Select One:
 This is the first time I am selecting a medical cannabis dispensary
 I am requesting a change in my medical cannabis dispensary
Name
Date of Birth
Patient Registry
QP.
Identification Number
EMAIL
Phone Number
Address
City
Name and Address of
Dispensary
Dispensary District
The Medical Cannabis Program will confirm your dispensary selection once it is processed.
You do not need to select a medical cannabis dispensary at this time. However, you must select a
dispensary in order to purchase medical cannabis. The list of dispensaries currently licensed with the
state of Illinois can be viewed at
http://www.idfpr.com/Forms/MC/ListofLicensedDispensaries.pdf
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