Your Full Name *

Your Email Address *

Date of Birth *
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Your Phone Number *

Are you a California resident and have a valid ID or proof of residency? *
---YesNo

Do you have a medical condition that could benefit from the use of cannabis?
(Arthritis, Chronic Pain, Gastrointestinal Disorders, Insomnia, Glaucoma, Movement Disorder, Depression, Anxiety, Cancer, Nausea, etc.) *
---YesNo

Have you been previously diagnosed for your condition? *
---YesNo

Do you have any medical paperwork to support your diagnosis?
(X-rays, MRIs, prescriptions, physician letters, medications or any other documentation showing that you have been to a doctor and have been diagnosed with your condition.) *
---YesNo

Do you have the name and contact information for your primary care physician and can you provide that information at the time of your appointment? *
---YesNo

Are you currently on probation or parole? *
---YesNo

Have Additional Questions/Comments?

* = required field.