Application Forms

Illinois Medical Marijuana Card Application Information

Important Information

Patients and caregivers can now apply for an Illinois Medical Marijuana Card online via the Illinois e-License System. You will need to submit passport photos and fingerprinting online, and your physician will need to send in his or her certification form separately. Please contact us if you have questions about this process.

These materials are for Patients, Caregivers and Physicians.

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Illinois Application Forms

Official State of Illinois Documents - Click to View

ON-LINE PATIENT APPLCATION

PRINT PATIENT APPLICATION

(includes Fingerprint Consent Form)

(Not for Terminal Illness)

VETERANS RECEIVING CARE AT A U.S. DEPARTMENT OF VETERANS AFFAIRS (VA) FACILITY, PLEASE SEE BELOW. IF YOUR INFORMATION HAS CHANGED (NAME, ADDRESS, ETC) PLEASE CLICK ON THE LINK ABOVE.

Veterans receiving health care at a VA facility do not need to provide a physician written certification, but must instead provide medical records from the VA facility for the last 12 months.
• Use VA form 10-5345 to request these records (U.S. Department of Veterans Affairs, Request for and Authorization to Release Medical Records and Health Information). If you have received care for your debilitating medical condition for more than 5 years at a VA facility, you must mark “OTHER” on VA Form 10-5345 under “Information Requested” then write that you are requesting information about the treatment of your qualified condition for the most recent 12-month period. Under “PURPOSE(S) OR NEED FOR WHICH THE INFORMATION TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED” write “Personal Medical Purposes”. Under “NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED” write your address. The records will be sent to you.
• To obtain VA medical records electronically, go online to https://www.myhealth.va.gov/index.html
• Once you receive your official medical records, you must submit the medical records with your application.

THE APPLICATION IS HERE

Anyone who has received a diagnosis of terminal illness, with a prognosis of less than 6 months of life, will have their application processed in no more than 2 weeks, will not require fingerprinting and will have their application fee waived.

FOR INFORMATION ON FILLING OUT THE TERMINAL ILLNESS REGISTRATION FORM

PLEASE NOTE: MINORS REQUIRE TWO PHYSICIAN CERTIFICATION FORMS. TWO CAREGIVERS ARE NOW ACCEPTABLE

PRINT THE APPLICATION FORM

DEPT OF HEALTH CHANGE FORM

A COMPLETE UPDATED LIST OF CANNABIS CARDHOLDER FEES

CLICK ON THE LINK TO GET TO THE FORM TO INCREASE A PATIENT'S 14 DAY ALLOCATION OF CANNABIS

If 2.5 oz of cannabis is not enough for your condition, you can fill out the attached form to increase your allocation.

PDI Medical offers state-certified fingerprinting and passport photo services for a nominal fee. Follow us on Facebook to be alerted of upcoming news and events.

We’re committed to helping Illinois patients manage the application process. Read about our recent Illinois Medical Marijuana Card credentialing event.

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  • Tuesday – 12pm – 7pm
  • Wednesday – 12pm – 5pm
  • Thursday – 12pm – 7pm
  • Friday – 10am – 4pm
  • Saturday – 10am – 3pm
  • Sunday – Closed

Convenient Location

1623 Barclay Blvd. Buffalo Grove, IL 60089

Call Today!  1-224-377-9PDI (9734)

PDI Medical is a Licensed
Illinois Medical Cannabis Dispensary
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