Name
*
First Name
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example@example.com
What is the OMMA Password you used to create your account?
Address
*
Street Address
Street Address Line 2
City
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*
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Date
-
Year
-
Month
Day
Date
My Products
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next
( X )
Returning Jiffy Patient
Thank you for your loyalty! Full Service recommendation. We upload your information to the State.
$
50.00
New Patient
Full Service recommendation. We upload your information to the State.
$
100.00
Renewal Patient
For Patients who need a renewal. We upload your information to the State.
$
75.00
DISPENSARY KIOSK-Full Service
You must be at a dispensary kiosk or patient drive for this special pricing. Dispensary will verify.
$
25.00
VETERAN-Full Service
Thank you for your dedicated service! Full Service recommendation. We upload your information to the State.
$
50.00
SENIOR-Full Service
65 or Older. Full Service recommendation. We upload your information to the State.
$
50.00
Pediatric-Doctor One
Full Service recommendation. We upload your information to the State.
$
35.00
Pediatric-Doctor Two
Full Service recommendation. We upload your information to the State.
$
35.00
Payment Methods
Credit Card
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
If Full Service, please upload your Driver's License here:
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For Our Full Service Patients ONLY.
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Are you a 100% Disabled Veteran?
*
Yes
No
If you answered yes to being a disabled veteran, please upload proof of your disability.
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If Full Service, please upload your insurance card here:
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Where do you want your medical card mailed?
Your OMMA State Fee that we will pay for you to get your Medical Card. Please read and then upload your payment method, front and back, on the next section.
If you have insurance, your State fee is $22.50 which is Medicare, Medicaid and Sooner Care. If no insurance, your State fee is $104.30.
Please upload the front and back copy of your payment method for Jiffy Doctor to pay your State Fees unless you are going to pay it yourself.
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Jiffy Doctor - Patient Registration
YOUR TIME YOU CHOOSE IS FOR OUR PROVIDER TO REVIEW YOUR INFORMATION. IT IS NOT YOUR DESIGNATED PHONE CALL TIME. WE WILL CALL YOU THE SAME DAY OF YOUR APPOINTMENT. OUR CUT OFF TIME IS 4:00 P.M. IF YOU REGISTER AFTER 4 P.M., YOU WILL BE CALLED THE FOLLOWING DAY. THANK YOU!
Click here to submit your forms and to be redirected to our booking section
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