Pre-Qualify - Alternative Care Clinics

Want to see if you pre-qualify? Fill out the form below and see if you qualify. This survey is COMPLETELY CONFIDENTIAL and will not be shared or sold to ANYONE.

First Name / Last Name

Date of Birth

Month	Day	Year
Phone Number

Email Address

Do you have a valid California ID?
Yes No
Do you have a medical condition that could benefit from the use of cannabis? (AIDS, Cancer, Migraines, Glaucoma, Asthma, Chronic Pain, Multiple Sclerosis, Nausea, Insomnia, depression, Anxiety, Anorexia or other serious illnesses)
Yes No
Have you been previously diagnosed for your condition?
Yes No
Do you have any medical paperwork to support your diagnosis? (X-rays, MRI’s, prescriptions, physician letters, medications or any other documentation showing that you have been to a doctor and have been diagnosed with your condition. )
Yes No
Do you have the name and contact information for your primary care physician and can you provide that information at the time of your appointment?
Yes No
Are you currently on probation or parole?
Yes No
Have you read our privacy policy?
Yes No ( view our privacy policy )
Which clinic location would you prefer to be seen at?

Comments / Questions

* All emails will be strictly confidential

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