Life Medical P.A.

4201 Excelsior ST. Louis Park, MN 55416

Tel : 952 933 8900 FAX : 952-945-9536



    acknowledge that I am paying $

    certification fee for medical cannabis certification

    I authorize Life Medical to charge my health insurance for today's visit with Dr.

    My certification fee will cover all the costs associated with my deductible, co-insurance

    and/or co-pays if any and I will not owe anything else for today's visit

    Patient's Name *

    Date *