Pre-Register
to Buy MA Medical
Marijuana at NEA

Save time during your first visit by filling out our medical marijuana registration form.

Pre-Registration
Form

NEA Medical Marijuana

Signing up as an NEA medical marijuana patient gives you access to the best cannabis products and staff in the East. If you don’t have your medical card yet and are interested in seeing if you qualify, please see our definitive guide to getting your medical marijuana card in Massachusetts.

Patient Full Name

Date of Birth

Address

GENDER MaleFemale

Phone

CERTIFIED PHYSICIAN FULL NAME

Physician Phone Number

Does the patient have a Caregiver? YesNo

If Yes, Caregiver’s Full Name

MA Marijuana for Medical Use Program ID

Date of MMJ Card Expiration Date

Secondary ID Number as Used in Patient Registration

How did you hear about us? MA Executive Office of Health & Human Services/Marijuana for Medical Use ProgramDoctor ReferralFriend ReferralEmployee ReferralOther ReferralSocial MediaGoogle / OnlineNews / MediaOther

I attest that I will not engage in the diversion of cannabis. I understand that fraudulent distribution of medical cannabis is a felony punishable by up to 5 years in prison.

Agree

I understand that my registration card only allows me to possess and use cannabis for medical purposes within Massachusetts.

Agree

I understand that cannabis has not been analyzed or approved by the FDA, including cannabis produced by Sapura.

Agree

I understand there is limited information on the side effects of cannabis, including cannabis produced by Sapura.

Agree

I understand there may be health risks associated with using cannabis, including cannabis produced by Sapura.

Agree

I understand cannabis, including cannabis produced by Northeast Alternatives, should be kept away from children.

Agree

I understand that when under the influence of cannabis that driving is prohibited under M.G.L. c. 90, s. 24, and machinery should not be operated.

Agree

I understand that I may not distribute medical cannabis to any other individual, and must return unused, excess or contaminated product(s) purchased at Sapura to a Sapura dispensary for disposal.

Agree

I agree at all times to abide by Massachusetts law in regards to my use of medical cannabis and hereby release and waive all claims against Northeast Alternatives from any and all liability related to my use of medical cannabis.

Agree

I agree not to bring any weapons or anything that can be used as a weapon into any Northeast Alternatives facility.

Agree

I agree not to use medical cannabis in a way that endangers the health and well-being of any person.

Agree

I understand that Northeast Alternatives may refuse to dispense cannabis to me if, in the opinion of the dispensary agent, the public or myself may be placed at risk by doing so. In this event, I understand that my certifying physician will be notified within 24 hours.

Agree

I authorize my information to be shared between Northeast Alternatives treatment facilities.

Agree

Re-Enter Patient Full Name

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Pre-Register to Buy MA Medical Marijuana at NEA

Pre-Registration Form

NEA Medical Marijuana

Exclusive products, prices, rewards.

Pre-Register
to Buy MA Medical
Marijuana at NEA

Pre-Registration
Form