Therapeutic Use Exemption Form
Request permission to use a prohibited substance or method for therapeutic reasons. Please complete all sections accurately.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Condition or Diagnosis
*
Prohibited Substance or Method Requested
*
Reason for Therapeutic Use
*
Prescribing Physician's Name
*
Prescribing Physician's Contact Information
*
Supporting Medical Documentation
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I confirm that the information provided in this application is accurate and complete to the best of my knowledge. I understand that my application will be reviewed and may require further information.
*
I acknowledge and agree
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