Appointment Request Form

To request an appointment, please complete the form below or call us at 203.951.5700

I am *
Name *
Name
Primary Phone Number *
Primary Phone Number
This should be a phone number that you are comfortable using in connection with your medical marijuana registration and treatment, as both the Department of Consumer Protection and REN Health will use them to communicate with you.
Are you a legal Connecticut resident? *
Home Address *
Home Address
Date of Birth *
Date of Birth
Please select your qualifying debilitating medical condition for which you are looking to be certified: *
Do you have current medical records that state your qualifying condition available now? *
Will you be able to provide REN Health with such records before or at the time of your appointment? *
(such as prescription medications, over-the-counter medications, herbal products, surgery, physical therapy, psychotherapy, acupuncture, injections, chiropractic, etc.)
When would you like to schedule your appointment? *