Want to see if you pre-qualify? Fill out the form below and see if you qualify.

This survey is COMPLETELY CONFIDENTIAL and will not be shared or sold to ANYONE.


First Name / Last Name
Date of Birth
Month
Day
     Year
Phone Number
Email Address
Do you have a valid California ID?
Do you have a medical condition that could benefit from the use of cannabis? (AIDS, Cancer, Migraines, Glaucoma, Asthma, Chronic Pain, Multiple Sclerosis, Nausea, Insomnia, depression, Anxiety, Anorexia or other serious illnesses)
Have you been previously diagnosed for your condition?
Do you have any medical paperwork to support your diagnosis?
(X-rays, MRI’s, physician letters, diagnosis or any other documentation showing that you have been to a doctor and have been diagnosed with your condition. )
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?
Are you currently on probation or parole?
Have you read our privacy policy?
Which clinic location would you prefer to be seen at?
Comments / Questions

 

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