Marijuana Cards Arizona

1
Full Name* This field is required.Enter in your name as it appears on your source of Identification- If you have two last names, please include both last names in the application
First Name
Last Name
2
WARNING: There may be potential dangers to fetuses caused by smoking or ingesting marijuana while pregnant or to infants while breastfeeding,” “WARNING: Use of marijuana during pregnancy may result in a risk being reported to the Department of Child Safety during pregnancy or at birth of the child by persons who are required to report”
3
Phone Number # * This field is required.Please enter a good number for the doctor and processing team to reach you at.
Phone number
4
How did you hear about us?* This field is required.Friends are entered into a raffle for free approval paperwork on their next renewal, businesses get extra goodies delivered!
5
Birth Date* This field is required.
Month
Day
Year
6
EmailFor Copy of Application
example@example.com
7
Address* This field is required.All the cards are digital but we need to ensure you are a resident of Arizona
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
USA
8
Is this your first or a renewal card?
First
Renewal but I am expired
Renewal
9
Are you receiving food stamps?
YESNO
10
What is your height and weight?
11
Where is your pain located specifically and what happened for the pain to begin?
Huge
Large
Normal
Small
Ok
Ok
12
Are you currently taking any medications to manage your pain?Please list medications below
13
On a pain scale of 1-10, how would you rate your pain levels this week?
1-2
2-3
4-5
6-7
8-9
10+
14
What does the pain feel like?Please select all that apply
Numb
Cramping
Pinching
Twisting
Unbearable
Pounding
Piercing
Shocking
Dull
Sharp
Intense
Stessed
15
Does the pain radiate? If so into where?
Huge
Large
Normal
Small
Ok
Ok
16
How long have you been managing this Chronic Pain?
1 Year
1-2 Years
2-4 Years
5-10 years
10 + Plus
17
What makes the pain better/worse?
Huge
Large
Normal
Small
Ok
Ok
18
Are you currently undergoing any therapy or treatment?If so, please explain
Huge
Large
Normal
Small
Ok
Ok
19
State FeeThe state fee of 150$ will be completed in the portal- AZDHS. We are not in any relation to AZDHS, we simply help you manage our documents into your portal to ensure you complete the process. We cannot pay AZDHS until we upload the doctors documents. Please continue to the next screen to submit this application to Dr Kira and she will prepare your approval documents for AZDHS. The TOTAL fee for your 2yr card is $255 after taxes. Assistance in the state website is included, assistance varies per patient terms on website.
YESNO
20
Medical Certificate and Evaluation- Assistance with State Processing included
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
TaxUSD
SubtotalUSD
Total costUSD
Certificate and Evaluation-State is SeperateThe state fee and processing will be step two after Doctor evaluation
$100.00Edit
Back
Expedite Doctor CertificationThis expedition will go to the Doctor to speed up completing your documents
$25.00Edit
Back
Enter Coupon
Total cost $0.00
Payment Methods
Credit Card
First Name
Last Name
Cash App
After submitting the form, you will be redirected to the Cash App Pay to complete the payment process.
Google Pay
After submitting the form, you will be redirected to the Google Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
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