Qualify Medical Cards - Medical Medicinal Cards

Please provide your contact information below. Our staff will contact you via phone and send you an informational email to determine if you are eligible for Medical Card certification. We look forward to speaking with you!

If you live in MN use this form to inquire about medical cannabis

Name*
Phone*
Email Address*
Date of Birth*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
*
- I understand that the state of MN requires that I am Minnesota resident.

Following conditions are below if you are seeking treatment for:
(to qualify for Minnesota Medical Card Program you must have at least one of these medical conditions.)

Cancer associated with severe/chronic pain, nausea or severe vomiting, or cachexia or severe wasting
Glaucoma
HIV/AIDS
Tourette Syndrome
Amyotrophic lateral sclerosis (ALS)
Seizures, including those characteristic of epilepsy
Severe and persistent muscle spasms, including those characteristic of multiple sclerosis
Inflammatory bowel disease, including Crohn’s disease
Terminal illness, with a probable life expectancy of less than one year*
Intractable pain
Post-traumatic stress disorder
Autism
Obstructive sleep apnea
Alzheimer’s disease
Chronic pain
Sickle cell disease (effective Aug. 2021)
Chronic motor or vocal tic disorder (effective Aug. 2021)

By Submitting the form above you are providing your mobile phone number and email address, and verify that it is my mobile number and email address and consent to receive phone and email regarding the Medical Card Certification process offered by Dodson Pain Consultants.

NOTE: Our office will contact you as soon as possible. Please call: 763-588-7099

This form will not submit until all required fields are filled in.

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Do you have your medical records?

The Minnesota Medical Card program requires that you have been diagnosed with a qualifying medical condition. Without the critical data in your medical records, it is possible we may not have enough information to complete your certification.

Please fax us copies of the records that verify and support your qualifying condition, and if you do not have those records please request copies faxed to our facility as soon as possible.

Use the form ROI-to-DPC. This is a standard Release of Information Form. Note* If you request records sent directly to Dodson Pain Consultants, your hospital/clinic typically won’t charge a fee.

FORM to Download: Release Of Information to DPC : ROI-to-DPC-MCC.pdf