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) *