How Does It Work?
Step 1: Fill out the extensive questionnaire which will document your medical history.
Step 2: Make payment at the bottom and WAIT 20 to 60 seconds while your profile is created.
Step 3: Give our staff 24 hours to review and approve your profile.

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Your information is safe and secure as we process on a H.I.P.A.A. server which is 256 bit encrypted
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First Name
Last Name
Email
Phone
Username
Password
Drivers Lic. or State ID
Date Of Birth
Address
Apartment #
City
State
Zip Code
Gender
Contact Me By
May I leave a voicemail?
Referred By
Qualify
Do You Have Any Drug Allergies?
Current Medications (Leave Blank If None)
Social Security #
Current Weight
Qualifying Conditions
Please select the condition(s) in which you seek Medical Marijuana for. If other please specify, field must not be blank.
Health History
Review the following conditions, check the conditions that you have been diagnosed with and treated for in the last year? *
You may select multiple options.
Review of Symptoms
Review the following symptoms, check the symptoms that are current and that you have been treated for in the past year: *
You may select multiple options.
Surgical History: Please list any surgeries and date of such surgery. *
Describe non-surgical treatments you have received/are receiving for your medical condition(s) for which you seek a recommendation of medical marijuana:
You may select multiple options.
Are you currently receiving treatment for the condition(s) that you are being evaluated for medical marijuana? *
History of mental illness or major health problems in your immediate family: parents, grandparents, or siblings? *
Please check if any of the following activities are substantially limited or impaired (i.e. pain/weakness/impaired strength or ability) by the medical condition for which you seek medical marijuana: *
You may select multiple options.
Have you used cannabis in the past to treat your medical condition? *
Do you have a history of substance abuse or addictions? *
Do you smoke tobacco? *
Preferred method of marijuana use as a medicine: *
You may select multiple options.
You do understand that smoking is harmful to your lungs and is not medically advised? *
Have you had any negative/adverse reactions from cannabis use? *
Additional Information that you consider relevant to the physician’s evaluation:
How likely are you to recommend us to someone you know?
Are there medical records that document your medical condition(s)?
Questions/Comments/Concerns/Suggestions
Records Release Request
Upload your prescription bottle by clicking below. * Make sure your name and the name of the prescription is visible.
Upload
HIPAA Patient Consent Form
Malpractice Insurance Notice
Informed Consent for Treatment with Medical Cannabis
Practice Consents
Digital Signature
By electronically signing this form, I declare under penalty of perjury that the information on this form is true and correct to the best of my knowledge and understand that the typed electronic signature shall have the same legal effect as an original signature.
Use Your mouse or finger to sign below. Click "Add Signature" after signing.
Payment
Payment
ORDER SUMMARY
Establish Care $99.00
Total $99
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