VIRGINIA - MEDICAL FORM
Renewal
Name
*
First Name
Last Name
State
*
Please Select
Virginia
Please select your state:
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Are you taking any medications?
*
Please Select
Yes
No
What medication are you currently taking?
Have you ever been diagnosed with schizophrenia?
*
Please Select
Yes
No
Have you ever experienced hallucinations before?
*
Please Select
Yes
No
For Adults Medical Conditions
*
Please Select
I am under 18 years old
Cancer
Glaucoma
Positive Status for Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome
Parkinson's Disease
Multiple Sclerosis
Damage to the Nervous Tissue of the Spinal Cord with Objective Neurological Indication of Intractable Spasticity
Epilepsy
Cachexia
Wasting Syndrome
Crohn's Disease
Post-Traumatic Stress Disorder
Sickle Cell Disease
Post Laminectomy Syndrome with Chronic Radiculopathy
Severe Psoriasis and Psoriatic Arthritis
Amyotrophic Lateral Sclerosis
Ulcerative Colitis
Complex Regional Pain Syndrome
Cerebral Palsy
Cystic Fibrosis
Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity
Terminal Illness Requiring End-Of-Life Care
Uncontrolled Intractable Seizure Disorder
Spasticity or Neuropathic Pain Fibromyalgia
Severe Rheumatoid Arthritis
Post Herpetic Neuralgia
Hydrocephalus with Intractable Headache
Intractable Headache Syndromes
Neuropathic Facial Pain
Muscular Dystrophy
Osteogenesis Imperfecta
Chronic Neuropathic
Degenerative Spinal Disorders
Interstitial Cystitis
MALS Syndrome
Vulvodynia and Vulvar Burning
Intractable Neuropathic
Tourette Syndrome
Chronic Pain of at least 6 months
Ehlers-Danlos Syndrome
Chronic Pancreatitis
For Patients Under 18 Medical Conditions Include:
Please Select
Cerebral Palsy
Cystic Fibrosis
Irreversible Spinal Cord Injury
Severe Epilepsy
Terminal Illness Requiring End-Of-Life Care
Uncontrolled Intractable Seizure Disorder
Muscular Dystrophy
Osteogenesis Imperfecta
Intractable Neuropathic Pain
Tourette Syndrome
Chronic Pancreatitis
Back
Next
How did you hear about us?
Upload Your Valid State ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Medical Documentation:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Video Appointment
*
My Products
*
prev
next
( X )
Schedule Online Appointment
Provide some basic medical history and book an appointment with a licensed marijuana doctor. The $169 fee includes your consultation fee, physician copay, and the medical evaluation for your recommendation.
$
169.00
Submit
Submit
Should be Empty: