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
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Montserrat
Morocco
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Namibia
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New Caledonia
New Zealand
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Nigeria
Niue
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Western Sahara
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Zambia
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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! .📧
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
Where is your pain located & How how many years have you been experiencing itWe 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
10
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. Maria, who will prepare your documents for the state. The total cost for your 2-year card is $255 after taxes. Please select "Yes" if you are ready to continue.
YESNO
11
My Products
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My Bag
1
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Great Product Name
$20
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
TaxUSD
SubtotalUSD
Total costUSD
Pain Certification and Examination Thank you for choosing us! The team at Marijuana Cards along with Dr Maria will provide the necessary documents you need to submit to the State.
$97.00Edit
Back
ExpediteThis has Dr Maria take your application to the front of the line, your paperwork will be processed with Maria first. State processing remains the same
$20.00Edit
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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