Patient Assistance Application

Patient Assistance Application

We will NEVER share your information with anyone at anytime! If you do not feel comfortable filling out this form online, please call one of our counselors at 602-903-802, we would be happy assist you offline!
Full Name

First NameLast Name
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Annual Income
Please Provide Household Income After Taxes
# in Household
# of People Living in Your Household
Are You Currently on Public Assistance
I am a U.S. Citizen
Do You Currently Have an MMJ Card
If Yes, Which State
Please Provide a Copy of Your MMJ Card (If Applicable)

Upload a File

Cancelof
Please List Your Current Medical Conditions
Are You Currently Using Cannabis?
What Barriers Have You Faced Accessing Cannabis?
What Are Your Primary Needs?
Other Need
Additional Information
Please provide any additional information you feel might be relevant.
How Did You Hear About Us?
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