Georgia Low THC Oil Registry

Please complete the registration form below. The symbol indicates that a field is required and must be provided.

Log In Information


Please enter your Email address, this will be used as your username:
Please enter a password:	- Must be at least 8 characters long

Physician Information


License Number:
Licence Expiration Date:	// 4-digit year required
DEA Number:
First Name:
Middle Initial:
Last Name:
Date of Birth:	// 4-digit year required
Last 4 digits of Physician's Social Security Number:

Physician Email:	This email address will be used by the system to communicate with you and must be the Physician's email address. Check here to use same email that was used for your username above.


Physician's Mailing Address


Address:
Address2:
City:
City:
County:
State:
Zip Code:
Telephone:	--
Fax:	--