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123456

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First Name *

Last Name *

Suffix

Middle Name

Email *

Phone *

Birth Month *

Month

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Birth Day *

Day

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Birth Year *

Year

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Age *

Gender *

Gender

Male
Female
Other
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Patient State

Select Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native

White

Street Address (No P.O. Box Allowed) *

City *

Postal code *

Apartment #

Immediate family medical issues (Indicate if you or your immediate family had any of the following problems)

None

Kidney Disease

Liver Disease

Migraines

Seizures

Alzheimer's disease

Arthritis

Asthma

Blood disorders

Cystic fibrosis

Dementia

Depression

Diabetes

Heart Attack

Heart Disease

High Blood Pressure

High cholesterol

Others

Are you currently employed? *

Yes

Do you drink alcohol? *

Yes

Do you smoke cigarettes? *

Yes

Do you have a history of drug abuse? *

Yes

ID Type *

Driver's License

State ID

Tribal ID

US Passport

ID Number *

I confirm that I have read and agree to the Terms & Conditions. I acknowledge that all data entered is 100% accurate, and I understand that a $9.99 form correction fee will apply if changes are required after submission.

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PATIENT INFORMATION

First Name *

Middle Name

Last Name *

Suffix

Email *

Phone (Unique number must be used for each account) *

Birth Date Month *

Month

January
February
March
April
May
June
July
August
September
October
November
December
No elements found. Consider changing the search query.
List is empty.

Birth Date Day *

Day

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
No elements found. Consider changing the search query.
List is empty.

Birth Date Year *

Year

2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
No elements found. Consider changing the search query.
List is empty.

Age *

Gender *

Gender

Male
Female
Other
No elements found. Consider changing the search query.
List is empty.

Select Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native

White

How Did You Hear About Us? *

How Did You Hear About Us?

Facebook
Website
Word of Mouth
Instagram
Google Search
Tiktok
TV Commercial
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Street Address Only (DO NOT INCLUDE CITY, STATE, COUNTRY) *

City *

Postal code *

Apartment #

County *

Select Your County

Adair County
Andrew County
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Washington County
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Wright County
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IDENTIFICATION

ID Type *

Driver's License

State ID

Tribal ID

US Passport

ID Number *

Upload ID Front *

Upload ID Front

QUALIFYING CONDITIONS

(Please select at least one to qualify. Required) *

Chronic Pain

Anxiety

Post-Traumatic Stress Disorder (PTSD)

Amyotrophic lateral sclerosis (ALS)

Autism

Cancer, including remission therapy

Chronic Hepatitis C

Crohn's disease

Damage to the nervous tissue of the central nervous system (brain-spinal cord) with objective neurological indication of intractable spasticity, and other associated neuropathies

Dyskinetic and spastic movement disorders

Epilepsy

Glaucoma

HIV/AIDS

Huntington's disease

Inflammatory bowel disease

Intractable seizures

Multiple sclerosis

Neurodegenerative diseases

Neuropathies

Opioid use disorder for which conventional therapeutic interventions are contraindicated or ineffective, or for which adjunctive therapy is indicated in combination with primary therapeutic interventions

Parkinson's disease

Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain

Sickle cell anemia

Terminal illness

Tourette syndrome

SOCIAL QUESTIONS

Are you currently employed? *

Yes

Do you drink alcohol? *

Yes

Do you smoke cigarettes? *

Yes

Do you have a history of drug abuse? *

Yes

UPLOAD PATIENT PHOTO *

For Passport - Need Utility Bill last 30 days or lease

Upload File

For Minor Patients - Minor Letter from Doctor with Diagnosis

Upload File

100% Disabled VET

Upload File

For Minor Patients - Minor Birth Certificate

Upload File

FOR RENEWAL PATIENTS

MMJ MEDCARD NUMBER

I confirm that I have read and agree to the Terms & Conditions. I acknowledge that all data entered is 100% accurate, and I understand that a $9.99 application correction fee will apply if changes are required after submission.

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