Prequalify for the AZ Medical Marijuana Program

If the following apply to you, please continue with the form and submit:

1. Must be able to show Arizona residency by providing a copy of one of the following: Arizona driver’s license, Arizona state issued identification card, Arizona registry identification card, or photograph page in your current US passport.

2. Not currently PREGNANT or diagnosed with SCHIZOPHRENIA.

** Please Note: If you fill in incorrect or misleading information you acknowledge that your attempt to obtain a marijuana recommendation is fraudulent and are in no way eligible to receive a chargeback or compensation.

Patient Information:
How did you hear about us? *
Choose your location *
Full Name *
E-mail Address * Phone Number *
Please Check those that apply
The patient is a current Arizona Resident *
The patient has a valid Arizona Drivers Licence or a state issued photo I.D. *
The patient is 18 years of age or older *
Do you have medical records from within the past 12 months for your qualifying condition(s) *
Is patient currently on probation or paroll *
I certify that I am 18 years of age or older*