Registration Form

New Mexico Medical Cannabis Program Card Application Zia Health and Wellness 740 San Mateo N.E Albuquerque 87110

Complete the form below to start your cannabis card Application Ap
Name

First NameLast Name
New PatientRenewalCaregiverUnder 18
E-mail
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityNew Mexico

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Medical Condition

Post traumatic stress disorder (PTSD)Autism Spectrum DisorderAnxiety DisorderCancerOpioid Abuse DisorderSevere Chronic PainInsomniaOther
Cannabis card number, For renewals only
Membership Type

2 Year renewal
Preferred way to contact

PhoneEmailAny
Should be Empty:

New Mexico Medical Cannabis Program Card Application Zia Health and Wellness 740 San Mateo N.E Albuquerque 87110