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Bryant E. Bojewski, DO
Certified in Medical Marijuana
NEW CERTIFICATION
RECERTIFICATION
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RECERTIFICATION FORM FOR
MEDICAL MARIJUANA
Last Name
Email
Phone
Enter as xx/xx/xxxx (month/day/year)
Street Address
Street Address Line 2
City
State
Zip code
MEDICAL REASON YOU NEED MEDICAL MARIJUANA:
*
Required
Anxiety
Amyotrophic Lateral Sclerosis
Autism
Cancer
Crohn's Disease
Damage to Spinal Cord w/Intractable Spasticity
Epilepsy
Glaucoma
HIV
Huntington's Disease
Inflammatory Bowel Disease
Intractable Seizures
Multiple Sclerosis
Opiate Use Disorder
Neuropathies
Parkinson's Disease
Post-Traumatic Stress Disorder
Severe Chronic/Intractable Pain
Sickle Cell Anemia
Tourette's Syndrome
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