Herbal Care Rx Payment Link

Consultation Payment Form

Please fill out and submit this form to make your payment to the doctor.
Your Name*
Email*

Confirmation EmailPlease write and confirm your email address above
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
New MMJ PatientRenewing MMJ Patient
NoYes
When does your card expire?

MonthDayYear
Date
Your Department of Health Patient ID #
If you do not have your patient ID number, you will need that before you can book your appointment. Feel free to ask for assistance at scheduling@herbalcarerx.com

Select the consultation that best applies to you.*

New MMJ Patient Consultation

Phone consultation with the doctor for MMJ card certification

$125

Renewing MMJ Patient Consulation

Phone Consultation with the doctor to renew your Medicinal Cannabis Certification

$75

New MMJ Patient Consultation for Veterans, SSI/Disability, Medicaid, SNAP/CHIP/WIC, PACE/PACENET

Discount specifically for those on Supplemental Security Income (SSI), Disability, Medicaid, SNAP/CHIP/WIC, PACE/PACENET, or Veterans,

$75

Enter coupon

Total

$0.00

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Consultation Payment Form