Patient Info Step 1 of 4 25% Government Issued ID*Accepted file types: jpg, jpeg.Please take a clear picture of your drivers license or government issued ID and upload it. Expires on:* Date Format: DD slash MM slash YYYY Date Date Format: YYYY slash MM slash DD Patient First Name:*Patient Last Name:*Patient Email:* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Ship to another address*YesNOAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone* Medical Complaint:*NewRecurrentDate Of Birth* Date Format: DD slash MM slash YYYY WHAT MEDICAL SYMPTOMS OR CONDITIONS DO YOU HAVE ?* Insomnia/Sleeping Disorders Depression Seizures Memory Loss Pain Headaches Nervousness Spasms Anxiety/Stress Panic attacks Neck or Back trauma Joint discomfort Please tell us more detail about specific medical condition(s):*Are you taking any medications ?*YesNoDo you smoke tobacco ?*YesNoDo you drink alcohol ?*YesNoHave you consulted other health care providers about your medical condition ?*YesNoHave you used medical cannabis to successfully treat your health problems in the past ?*YesNoHave you had surgery or broken any bones ?*YesNoHave you noticed any bad effects from using Cannabis ?*YesNoHigh blood pressure ?*YesNoDiabetes ?*YesNoThyroid ?*YesNoSeizures ?*YesNoOthers ?*YesNoHeart Disease ?*YesNoLung Disease ?*YesNoKidney Disease ?*YesNoLiver Disease ?*YesNoBrain or Neurologic disease ?*YesNoGlaucoma ?*YesNoHIV ?*YesNoCancer ?*YesNoOperations (Surgeries ?)*YesNoMinor Psych, ADD, ADHD ?*YesNoMajor Psych, Bipolar, Major Depression, Schizophrenia, Hearing voices ?*YesNoPlease write any other information that might be useful to the doctor:* Certificate Type*Select Certificate TypeWithout Pic $49.00With Pic $70.00Want a Copy*Yes $10.00No $0.00Total $0.00 Upload Image*
