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Name as it appears on your ID *

First Name

Last Name

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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New Patient or Renewal *

New Patient

Renewal

Qualifying Medical Condition *

Check All That Apply

ALS (Amyotrophic Lateral Sclerosis)

Cancer

Glaucoma

Lupus

Epilepsy

Multiple Sclerosis

Rheumatoid Arthritis

HIV/AIDS

PTSD (must have psychiatric diagnosis)

Cachexia or wasting syndrome

Severe pain

Severe nausea

Seizures

Epilepsy

Severe and persistent muscle spasms

Crohn’s disease

IBS

Are you planning to grow your own cannabis plants at home? *

Yes

No