Step one widget with payment

First Name *

Last Name *

Email * Male Female

Phone * Mobile Landline

Driver's License Number *

Date of Birth *

State *

City *

County *

ZIP Code *

Residential Address *

Referred By

Care Taker Detail

Full Name *

Email *

Date of Birth *

Driver's License Number *

Social Security No. *

Phone No. *

Address *

Certification for Medical Marijuana (Minor Patient must have second opinion letter and medical records.)

Prescribed medication Medical records with a qualifying diagnoses Second opinion letter (A second opinion letter from a Medical doctor who is a MD or DO that will state that the benefits of Medical Marijuana will likely outweigh the risks)

You acknowledge that you will provide the state required documentation for your minor child.