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PATIENT REGISTRATION FORM HOSPITAL FOR SPECIAL SURGERY 535 East 70th Street NEW YORK, NY 10021 MEDICAL RECORD NUMBER DATE OF VISIT HOSPITAL PHYSICIAN PATIENT'S FULL NAME (last, first, MI.) DATE OF

Address) (no. city, no. state, no. zip code) (no. hospital or health care facility), if applicable (no. phone number) Please use the below form solely for registering patients for appointments and/or treatments for primary care or for any condition for which they would enroll only in another state that utilizes the Medical Marijuana Program. The information on this form is used strictly for the purpose of registering patients for medical marijuana use, and should not be used for any other purpose. State and federal government may regulate the use of marijuana, so the information provided here will only be used to assist registered patients and caregivers in their applications, including for registration, registration renewal, and to maintain records of such use for the purposes of determining eligibility. It will not be used to discriminate against a patient, caregiver, or medical marijuana cultivation facilities.

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