The information that you provide goes directly to us, and is kept on record and confidential. Please keep your information current. Thank you!

Membership Agreement

Pianta Tinta Collective

PIANTA TINTA COLLECTIVE is dedicated to providing our members with the highest level of quality service pursuant to the Compassionate Use Act. In order to be legal and compliant and also ensure the safety of our members, it is manditory that it be filled out. 

Members agree to provide current contact information to PIANTA TINTA COLLECTIVE. This information must be kept current at all times. Failure to maintain current information shall result in termination of membership. 

In addition to filling out this membership form, please email us a copy of your Physicians recommendation and a copy of your California Drivers License to piantatinta@gmail.com.

If you cannot scan and email them, please take a clear photo with your phone and attach it to the email. We will then acknowledge receipt via email.....your name will be added to our email list so that we can keep you updated on important news...thanks!

Name *
Name
Address *
Address
Phone *
Phone
Enter your phone number including area code
Physician phone *
Physician phone
Enter phone number of Physician
Please enter your diagnosis or medical condition
I understand and agree as follows; I am a qualified patient protected by California Health and Safety Code 11362.7, Proposition 215 and Senate Bill 420. My Doctor has recommended the use of medical cannabis and provided written documentation of such recommendation. My doctor will review my case on a yearly basis. Per the relevant sections of California law, I am able to possess, use, and cultivate cannabis for medical purposes. I agree to follow all the rules and guidelines of the collective. Disclaimer – General Release, Indemnification and Hold Harmless Clause: I, Being of lawful age and sound mind, do now release, acquit and forever discharge Pianta Tinta from all actions, claims, demands, or damages accruing to me from any known or unknown injury, loss or damage sustained by or to me. This release shall remain if force and run concurrently with my membership. I further agree to indemnify and hold harmless Pianta Tinta from any injuries or damages resulting from use or misuse of the medical cannabis products obtained from the collective. I, as a member of Pianta Tinta Collective, have been advised at the onset of accepting membership, that any representations or recommendation made by the staff at Pianta Tinta is not an examination, diagnosis, or a prescription by a person licensed to practice medicine in this state and therefore must not be regarded as medical opinion. I hereby agree to join the Pianta Tinta Collective.
Date
Date