Full Name *

E-Mail *

Phone Number

How did you hear about us? * Select one...PhysicianPatientAzmarijuana.com$100 CardFlyerGoogle AdInternet SearchCraigslistTV CommercialBillboard or Road SignEmailDispensary

Do you have a valid Arizona driver’s license, a state-issued ID, or US Passport? * YesNo

Please state why you’d like to obtain your medical card AND choose a qualifying condition below: *

Severe and chronic pain

Glaucoma

Cancer

Crohn’s Disease

Cachexia or wasting syndrome

Severe and persistent muscle spasms

Post Traumatic Stress Disorder (PTSD)

Amyotrophic Lateral Sclerosis (ALS)

Seizures or epilepsy

Hepatitis C

Alzheimer’s Disease

How soon would you like an appointment? (This is not a booking - we’re just curious) *

In which clinic location are you interested? * Select one...North Phoenix (Union Hills & 19th Ave)Scottsdale (Pinnacle Peak & Scottsdale)Tempe (101 & Warner)

I certify that I have Arizona residency with Arizona state ID, Arizona driver’s license, OR US Passport. I also attest that I am not currently on parole or probation. (Please do not submit if you cannot attest to BOTH) *