Nationwide health services

1
What is your First and Last Name?Enter in your name as it appears on your drivers license/ID/Passport*; If you have two last names please include both last names in the application. (*middle name not required)
2
What is the best Phone Number for us to contact you at?* This field is required.Please enter a good number for the doctor and processing team to reach you at.
Phone number
3
How did you hear about us? Referrals are entered into a raffle for a free certificate, and dispensaries get extra goodies!
4
What is your Date of Birth?* This field is required.On your phone you can click the month/year and then scroll down to your year of birth easily. If you are on a computer, you can type it in easily with the format mm-dd-yyyy.
Month
Day
Year
5
We need to verify You Are A Resident Of The State* This field is required.Please provide your current address
Street Address
Street Address Line 2
City
State
Postal / 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
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Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
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Colombia
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Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
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Egypt
El Salvador
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Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Hungary
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Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
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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
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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
Country
6
What is your Email Address?* This field is required.Make sure the information is correct and check your junk folder. If this is your first time with us, once you move the email to the primary folder you should get the rest of our emails easily! .📧
example@example.com
7
Is this a first or renewal card?
First
Renewal
Renewal but I am expired already
8
Do you receive SNAP benefits?Food Stamps card or benefit letter will be requested
YESNO
9
What is your height and weight?
10
Where is your pain located & How did the injury occur?We will discuss this thoroughly over the phone! Just give us the basics here specifically the location of your pain.
Huge
Large
Normal
Small
Ok
Ok
11
Are you taking any medications currently to manage your pain?
12
On a scale from 1-10, how would you rate your pain this eeek?
1-2
2-3
4-5
6-7
8-9
10+
13
What does the pain feel like?
Numb
Cramping
Pinching
Twisting
Unbearable
Pounding
Piercing
Shocking
Dull
Sharp
Intense
Stressed
14
Does the pain radiate?If so into where?
Huge
Large
Normal
Small
Ok
Ok
15
How long have you been managing this chronic pain?
1 year or less
1-2 years
2-4 years
5-10 years
10+ years
Other
16
What makes the pain better or worse?
Huge
Large
Normal
Small
Ok
Ok
17
Are you currently undergoing any therapy or treatment?If so, please explain.
Huge
Large
Normal
Small
Ok
Ok
18
State feeThe state fee of $150 (or $75 with EBT) will be completed on the portal-AZDHS. We are in no relation to AZDHS, simply here to assist taking our documents and uploading into your portal. We cannot pay AZDHS until the documents are uploaded. Please proceed to the next screen to submit this application to Dr. Kira, who will prepare your documents for the state. The cost for your 2-year card is $255. Please select "Yes" if you are ready to continue.
YESNO
19
My Products
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My Bag
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$20
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ORDER SUMMARY
TaxUSD
SubtotalUSD
Total costUSD
Medical Certificate- Guaranteed Approval Guaranteed Approval
$100.00Edit
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Expedite the DoctorHas the doctor create your paperwork before the other patients.
$25.00Edit
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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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