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Name: Etain Forte
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Patient/Caregiver Registration / Citiva New York

Tip: Before you begin filling out this form, scan or take a picture of your medical marijuana ID card and patient certification form. If you have a temporary medical marijuana ID card, you will need a copy of the temporary card and patient certification form ready for upload.

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date of birth

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If you have a caregiver, please provide us with the caregiver's name at the end of this form.

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NY Registry Identification Card (Front)

Please upload a scanned image of picture of the signed patient certification from your physicianPlease upload a picture of the FRONT of your medical marijuana program registry identification card mailed to you by the NYS Department of Health.!

*Required Field

NY Registry Identification Card (BACK)

Please upload a scanned image of picture of the signed patient certification from your physicianPlease upload a picture of the BACK of your medical marijuana program registry identification card mailed to you by the NYS Department of Health.!

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NY Patient certification

Please upload a scanned image of picture of the signed patient certification from your physician

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is there any additional information you would like to share with our pharmacy team?

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Complete These Steps Prior to Your First Order

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New York City Delivery Schedule

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Hudson Valley Delivery Schedule

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LOW CBD:HIGH THC

Etain Forte

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1:20 High THC ratio
2.8mg THC per dose

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Citiva Brooklyn 202 Flatbush AVE, Brooklyn, NY 11217 (Across from Barclays Center®) MON-SAT: 12PM-8PM SUN: 12PM-6PM Tel: 212.257.3145

Citiva Hudson Valley 1147 Route 9, Wappingers Falls, NY 12590 (Across from Hudson Valley VW) WED-FRI: 10AM-6PM TUES & SAT: 10AM-4PM SUN-MON: CLOSED Tel: 212.257.3145

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Please Send Us Your Info To Schedule a Pharmacist Meeting

GREAT NEWS!

Thank You

WE DO NOT DELIVER TO YOUR AREA AT THIS TIME.

Please Login to Your Account

Follow the steps in the link to obtain a New York State Medical Marijuana ID card

Before you can place an order, please register for an online account.

Yes

No

Patient Home Delivery Throughout New York

Complete These Steps Prior to Your First Order

I need to obtain a medical cannabis ID card first

I need to meet with an in-store pharmacist

Patient Home Delivery Throughout New York

Complete These Steps Prior to Your First Order

I need to create a registered account on

I’m ready to place an Online Delivery Order

New York City Delivery Schedule

Call 845-875-8590

Hudson Valley Delivery Schedule

Call 845-875-8590

LOW CBD:HIGH THC

Etain Forte

Related Products

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Schedule a Pharmacist Meeting