Please complete this online form to expedite your application for your medical marijuana card.Is visit for a New Card or Renewal?(Required) New Medical Marijuana Card Renew My Medical Marijuana Card OtherIs this for In-Person or via Tele-Health?(Required) Tele-Health In-Person OtherName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do you want your new card mailed to the same address on your ID? Yes, Different Address than on ID Same Address on IDName(Required) First Last Where to Mail New Medical Marijuana Card (If different that address on ID)(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number(Required)Email(Required) Please Upload A Picture Of Your Current Driver's License Or State ID(Required) Drop files here or Select filesMax. file size: 5 MB, Max. files: 3. Please enter your Driver's License or State ID NumberMedical HistoryWhat is your health concern/s that you believe would be improved by using medical marijuana?(Required)Pain, Anxiety, Sleep Issues, etc.?How long have you been dealing with this concern?(Required)Any Treatment History(Required)If you have been treated for this before, please provide some information about your treatment.Please check any that apply to your medical history EMG Injections Other StichesPlease check any that apply to your medical history X-Ray CT MRI ScopeAre you currently receiving any medical treatment?(Required) Yes NoIf you have any allergies, please list them here.Have you been admitted to a hospital or had any surgery within the last two years?(Required) Yes NoSmoking History(Required) Non-Smoker Current Smoker Former SmokerAlcohol History(Required) More than one drink per week Non-Drinker Former DrinkerAre you currently taking any medication?(Required) Yes, I am taking medications No, I am not currently taking any medicationsIf you are taking any medication, please list it/them hereHave there been any significant changes with your health during the last six months? If yes, please explain.(Required)When was your last medical visit or check-up?(Required)Have You Ever Had A Peculiar Or Adverse Reaction To Any Medicine Or Injections?*(Required) Yes No Maybe/Not SureIf yes, please explainDo You Have Any Prosthetic Or Artificial Limbs?(Required) Yes No Maybe/Not SureIf yes, please explainDo You Have Any Conditions Or Therapies Which Could Affect Your Immune System?(Required) Yes No Maybe/Not Sure(For Example: Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy)If yes, please explainAny Additional Information?Please include any additional information that you would like to share here.CAPTCHA