Your Name (required)

Your Email (required)

Your Phone Number (required)

How would you like us to update you on your qualification status? (required)
EmailPhone

What's the condition for which you want to use MMJ for? (required)

Do you have any type of medical documentation that pertains to the condition above?* (required)
YesNo

Any other information you would like to provide?

*Proper medical records consist of a physician progress note or hospital discharge summary pertaining to the qualified condition for which MMJ is requested. If you have the improper documents it can delay the process in getting a MMJ Card. X-rays, CT's or MRI's are only useful if they pertain to qualified condition.