New Patient Registration

Call to become a registered patient 614-612-1240

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Welcome to Bloom!

If this is your first visit to Bloom, please feel out the form below to expedited your first visit.

Before beginning make sure you have the following documents ready:

Current Contact Infomation
State Identification
Medical Marijuana Card

Please make sure to bring your active government ID and your medical card with you to the dispensary for every visit.

Contact Info

First Name *

Middle Initial

Last Name *

Phone Number *

Email Address *

Street Address (Line 1) *

Street Address (Line 2)

State *

ZIP Code *

State Identification

Driver's license or alternative state identification *

ID Expiration Date *

Birthday *

Medical Marijauna Card # *

About You

Are you a veteran? *

Yes

Financial Assistance *

Yes

Rate your experience with Medical Marijuana *

1 (Beginner)

5 (Expert)

Which products are you interested in?

Flower

Edibles

Concentrates

Tinctures

Vaporizer Pens

Transdermal Patches

Salve Cream

How did you hear about us? *

Friend/Family

Physician

Website

Internet Search

Patient Specialist

Other

We know you may have questions or concerns. Would you like a free consultation with our staff today? *

Yes

Would you like to receive marketing emails and text messages? *

Yes

Caregiver Info

Do you have a caregiver? *

Yes

Caregiver Name

Caregiver ID #