New Cannabis Card IntakeFill out the form below prior to your appointment with us. Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Terms & Conditions for Medical Cannabis: https://www.cannabiscardslogan.com/terms-and-conditions * I have read and agree to the terms above What is your qualifying condition and approximately how long have you had it? What have you tried? Have you had any tests or imaging studies? Please list all current medications: Thank you!
