First Name *
Last Name *
Age *
Email *
Phone Number *
Condition #1 * —Please choose an option—ADD/ADHDALSAnxietyBulging DiscCancerCarpal TunnelCrohn's Disease/Ulcerative ColitisDegenerative Disc DiseaseDegenerative Disc DiseaseDepressionDiabetesEpilepsy/SeizuresFibromyalgiaGlaucomaGoutHeadaches/MigrainesHerniated DiscHIV/AIDSIrritable Bowel Syndrome (IBS)LupusMultiple SclerosisNeuropathic PainNeuropathyPanic AttacksParkinson's DiseasePTSDRheumatoid Arthritis/OsteoarthritisSciaticaSevere Muscle SpasmsSleep Disorder/InsomniaStroke or Brain BleedTremors
Condition #2 —Please choose an option—ADD/ADHDALSAnxietyBulging DiscCancerCarpal TunnelCrohn's Disease/Ulcerative ColitisDegenerative Disc DiseaseDegenerative Disc DiseaseDepressionDiabetesEpilepsy/SeizuresFibromyalgiaGlaucomaGoutHeadaches/MigrainesHerniated DiscHIV/AIDSIrritable Bowel Syndrome (IBS)LupusMultiple SclerosisNeuropathic PainNeuropathyPanic AttacksParkinson's DiseasePTSDRheumatoid Arthritis/OsteoarthritisSciaticaSevere Muscle SpasmsSleep Disorder/InsomniaStroke or Brain BleedTremors
Condition #3 —Please choose an option—ADD/ADHDALSAnxietyBulging DiscCancerCarpal TunnelCrohn's Disease/Ulcerative ColitisDegenerative Disc DiseaseDegenerative Disc DiseaseDepressionDiabetesEpilepsy/SeizuresFibromyalgiaGlaucomaGoutHeadaches/MigrainesHerniated DiscHIV/AIDSIrritable Bowel Syndrome (IBS)LupusMultiple SclerosisNeuropathic PainNeuropathyPanic AttacksParkinson's DiseasePTSDRheumatoid Arthritis/OsteoarthritisSciaticaSevere Muscle SpasmsSleep Disorder/InsomniaStroke or Brain BleedTremors
Additional Notes
I certify that the details provided are true to the best of my knowledge. I understand that furnishing false information will result in application being denied and that completion of this application does not constitute an approval of Medical Marijuana certification. Lastly, I acknowledge that I may receive Medical Marijuana related solicitation from one of our licensed professionals.
