Patient/Caregiver Change of Name Form

I am requesting to change my name on the following registration(s):

Patient Registration

Caregiver Registration

Email ( A copy of this request will be delivered to the email address provided)

Patient Information

Patient ID/License Number

Patient Type

Caregiver Information

Caregiver ID/License Number

Address Information

To change your name please upload a copy of your Maryland State-issued Driver's License or Identification Card. MCA only accepts forms of ID issued by Maryland's MVA. (Driver's License or Identification Card)

Click Here to Upload

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First Name

Last Name

Choose how to sign

Draw Type

I authorize the Maryland Cannabis Administration to change my Patient/Caregiver Name.