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Medical Cannabis Delivery
   
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Registration Form

Home  > Registration Form


Name*

First Name*

Last Name*

Date Of Birth*

E-mail Address

California Dr. License Or I.D. Number*

Delivery Address*

Address1*

Address 2

City*

State*

Zip Code*

Phone Number*

Doctor's Information*

Doctor's Name*

Doctor's License Number*

Verification*

Verification (doctor's) Phone Number1*

Verification (doctor's) Phone Number2

Online Verification Website Address*

Recommendation Issue Date*

Recommendation Expiration Date*

Patient ID or Chart Number*

Referral Source

Choose One


By submitting the form above you are agreeing to our membership rules and regulations, our website terms of use and you agree to follow senate bill 420, proposition 215 and any other applicable state regulations.

Your digital signature means you are liable for the accuracy of the information you provide.
We will need to verify your valid California drivers license (or ID card) and your original doctors recommendation. Please also have a copy of your recommendation available for our driver to take when they arrive at your location. (If you do not have a copy, let us know) we’ll bring a copy machine.

Today Special
1oz with donation for only $100
1oz with donation for only $100
 
 
 
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