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6
Birth Date* This field is required.
Month
Day
Year
7
Do you live in one of the following states?* This field is required.Alabama Arkansas Colorado Connecticut Delaware District of Columbia Florida Idaho Illinois Indiana Kentucky Maryland Nebraska New Hampshire New York North Dakota Minnesota Mississippi South Carolina Tennessee Texas Utah Vermont Washington West Virginia Wisconsin Wyoming
YESNO
8
Please enter your preferred language below. (optional)
9
What medical condition or symptom is prompting you to apply for a medical cannabis card?* This field is required.Please refer to your state specific website for qualifying medical condition
10
How long have you been experiencing this medical condition or symptom?* This field is required.
11
Please upload a copy of front and back of your drivers license or passport* This field is required.
Drag and drop files here
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Max. file size: 10.6MB
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12
Some states require patients to have a bonafied relationship with a provider before a card can be issued. If you reside in one of those states, and two visits are required, do you plan to use Self-Pay or Insurance for your initial visit?* This field is required.
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Insurance
Self-pay
13
Please upload a copy of you insurance card front/back
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Max. file size: 10.6MB
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14
Our office uses athenahealth, a secure and trusted electronic health record system that includes a convenient patient portal designed to help you stay connected to your care. Through the portal, you can easily access your medical records and test results, send secure messages to our office, request or manage appointments, complete forms ahead of your visit, participate in telehealth appointments when available, and view or pay bills. The patient portal gives you safe, 24/7 access to your health information and helps streamline communication with our care team from your computer or mobile device.

How to download the athenaPatient app:

• Apple App Store (iPhone/iPad):
https://apps.apple.com/us/app/athenapatient/id1644169294

• Google Play Store (Android):
https://play.google.com/store/apps/details?id=com.athenahealth.athenapatient

Once you are a registered patient in our system, you will receive an invitation to create your own username and password, which will be securely linked to the patient portal.
15
Signature* This field is required.I attest that I will not divert marijuana to any individual who or entity that is not allowed to possess marijuana pursuant A.R.S. Title 36, Chapter 28.1 and that the information provided in the application is true and correct.
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16
My Products* This field is required.
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My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
Medical Cannabis Certification
$75.00Edit
Back
Total cost $0.00
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Expiration Year
Billing Address
Street Address
Street Address Line 2
City
State / Province
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
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
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
Svalbard
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
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