MedCardMD West Virginia Qualification & Intake

MedCardMD West Virginia Qualification & Intake

Complete this brief pre-screening to request a 100% virtual medical cannabis card appointment.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Are you a West Virginia resident?
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is this a new card or renewal?
What is your qualifying condition?
Briefly describe your condition and current treatment
Do you have medical records documenting your condition?
Upload medical records (optional)

Cancelof
Preferred appointment time
How did you hear about us?
Electronic Signature
Should be Empty: