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.
New or Renewing Patient*

New MMJ PatientRenewing MMJ Patient
Has your card already expired?

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 Product Image

New MMJ Patient ConsultationPhone consultation with the doctor for MMJ card certification

$125

Renewing MMJ Patient Consulation Product Image

Renewing MMJ Patient ConsulationPhone 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 Product Image

New MMJ Patient Consultation for Veterans, SSI/Disability, Medicaid, SNAP/CHIP/WIC, PACE/PACENETDiscount specifically for those on Supplemental Security Income (SSI), Disability, Medicaid, SNAP/CHIP/WIC, PACE/PACENET, or Veterans,

$75

Enter coupon

Total

$0.00

Credit/Debit Card

If you have time we'd love to know how you heard about us! (if multiple, please select the most influential)

Radio advertisementPhilly Metro PaperPittsburgh City PaperChestnut Hill LocalEmail ad or pop up ad on computer/phoneRedditFacebook/InstagramWord of mouth (friend, family, etc)Search engine (Google, Yahoo,etc)Dispensary recommendedDoctor recommendedI'm a returning patientOther
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Consultation Payment Form

Credit/Debit Card