Register below to be on file as a Caregiver for a Peninsula Alternative Health patient.  Registration prior to your visit helps expedite your initial consultation and pick up to obtain medicine for a patient. 

Number format should be the same as it appears on your cannabis card.
Caregiver ID Card Expiration Date *
Caregiver ID Card Expiration Date
Caregiver Name *
Caregiver Name
Caregiver Birth Date *
Caregiver Birth Date
Caregiver Address *
Caregiver Address
Caregiver Phone Number *
Caregiver Phone Number
Patient MMCC ID Expiration *
Patient MMCC ID Expiration
Patient Condition *
Select all that apply