Membership Application

PLEASE NOTE: Synergy Wellness is operating under the Medical Cannabis laws of California. Our products are medically oriented, not recreational. Therefore, all members need to have a doctors recommendation, photo ID and fill out the membership application on this page. We can ship to California addresses only. We anticipate this will be the operating procedure thru out 2018. 

  • STEP 1: Complete this online form. This form works for computers and tablets, but not all mobile devices.
  • STEP 2: Email a copy of your doctor’s recommendation and photo ID (driver's License) to info@synergycbd.com. You can scan an attachment or take a picture of it with a smart phone if you don’t have a scanner. To acquire a doctor's recommendation online, we suggest NuggMD.com

Thank you for your interest in Synergy Wellness.

Synergy Wellness - Membership Application 

Name*
Address:*
Address Line 2:
Additional address info:*
Phone:*
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E-mail:*
Confirm E-mail:*
Doctor's Name:*
Doctor's Phone:
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Doctor's Recommendation Expiration Date*
Medical Condition:*
Where did you hear about Synergy Wellness? *

I understand and agree as follows;

I am a qualified patient protected by California Health and Safety Code 11362.7, Proposition 215 and Senate Bill 420. My Doctor has recommended the use of medicalcannabis and provided written documentation of such recommendation. My doctor will review my case on a yearly basis. Per the relevant sections of California law, I am able to possess, use, and cultivate cannabis for medical purposes. I agree not to sell Synergy Wellness products to third parties. I agree to follow all the rules and guidelines of the collective.

Disclaimer – General Release, Indemnification and Hold Harmless Clause:

I, Being of lawful age and sound mind, do now release, acquit and forever discharge Synergy Wellness from all actions, claims, demands, or damages accruing to me from any known or unknown injury, loss or damage sustained by or to me. This release shall remain if force and run concurrently with my membership. I further agree to indemnify and hold harmless Synergy Wellness from any injuries or damages resulting from use or misuse of the medical cannabis products obtained from the collective.

I, as a member of Synergy Wellness Collective, have been advised at the onset of accepting membership, that any representations or recommendation made by the staff at Synergy Wellness is not an examination, diagnosis, or a prescription by a person licensed to practice medicine in this state and therefore must not be regarded as medical opinion. In addition, I acknowledge that I am not employed by any law enforcement or regulatory agencies.

I hereby sign and agree to join the Synergy Wellness collective.

Signed:*

Your full name here is a legal signature.

Signed Date:*

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FOR OFFICE USE ONLY:

Verified by:
Date Verified: