Georgia Low THC Oil Registry
  Physician Registration

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: //
 DEA Number:
 First Name:
Middle Initial:
 Last Name:
 Date of Birth: //
 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
 Zip Code:
 Telephone: --
Fax: --

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