Pre-register

Name
Phone
Birth Date
Government Issued ID
Date of Expiration
Address
City
State
Zip Code
Dr. Name
Dr. Phone
Dr. Verification Site
Recommendation Number
Date of Expiration
Completed Membership Form
Dr's Recommendation
Drivers License
Picture
How did you hear about us?
How would you like to be contacted?
Symptoms



Currently using, or have in the past used cannabis

Has medical cannabis helped to relieve your symptoms

Preferred Strain

Methods used to consume Cannabis
Estimated cannabis use
How long have you used cannabis
Do you know how cannabis affects you?

Has the amount of cannabis needed to control your symptoms changed over time?

How has your cannabis consumption changed in the last six months

What do you attribute the change to
Have you ever stopped using cannabis and had your symptoms return or worsen?