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.

Patient Information:
Full Name *
E-mail Address * Phone Number *
Have you been treatedt by a physician in the past 12 months for your qualifying condition(s)?