You can always press Enter⏎ to continue
Welcome
Hi there, please fill out and submit this form.
15
Questions
START
1
Select your State
*
This field is required.
New York
Arizona
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
Pennsylvania
Virginia
Washington D.C.
New York
New York
Arizona
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
Pennsylvania
Virginia
Washington D.C.
Previous
Next
Submit
Press
Enter
2
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
3
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
4
Phone Number
*
This field is required.
Please enter a valid phone number.
Previous
Next
Submit
Press
Enter
5
Date of Birth
*
This field is required.
Date (mm/dd/yyyy)
Previous
Next
Submit
Press
Enter
6
Date of Birth
-
Date
Month
Day
Year
Previous
Next
Submit
Press
Enter
7
Gender
*
This field is required.
Male
Female
Previous
Next
Submit
Press
Enter
8
Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Previous
Next
Submit
Press
Enter
9
Upload a Valid State ID
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
10
Are you taking any medication?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
11
Have you ever been diagnosed for schizophrenia?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
12
Medical History - Have you ever been diagnosed for the following conditions?
*
This field is required.
Chronic Pain
Post-Traumatic Stress Disorder (PTSD)
ALS
Cachexia
Multiple Sclerosis
Parkinson's Disease
Epilepsy
Spinal Cord Injury with Spasticity
Neuropathy
Crohn's Disease
Alzheimer's Disease
Cancer
HIV or AIDS Positive
Inflammatory Bowel Disease
Huntington's Disease
Hydrocephalus with Intractable Headache
Wasting Syndrome
Muscular Dystrophy
Neuropathic Facial Pain
Osteogenesis Imperfecta
Post Herpetic Neuralgia
Severe Rheumatoid Arthritis
Sickle Cell Disease
Spasticity or Neuropathic Pain Associated with Fibromyalgia
Post Laminectomy Syndrome with Chronic Radiculopathy
Severe Psoriasis and Psoriatic Arthritis
Amyotrophic Lateral Sclerosis
Ulcerative Colitis
Complex Regional Pain Syndrome
Terminal Illness Requiring End-Of-Life Care
Cerebral Palsy
Cystic Fibrosis
Uncontrolled Intractable Seizure Disorder
Interstitial Cystitis
MALS Syndrome
Vulvodynia and Vulvar Burning
Intractable Neuropathic Pain that is Unresponsive to Standard Medical Treatments
Tourette Syndrome
Ehlers-Danlos Syndrome
COVID-19 (Depression, Anxiety, Paranoia)
Other Condition
Previous
Next
Submit
Press
Enter
13
Invoice ID
Previous
Next
Submit
Press
Enter
14
Pick a preferred date and time
*
This field is required.
Previous
Next
Submit
Press
Enter
15
How did you hear about us?
*
This field is required.
Previous
Next
Submit
Press
Enter
16
Terms and Conditions
*
This field is required.
1. I am over the age of 21 years old. 2. I will keep away from children. 3. I will avoid operating heavy machinery and driving under the influence of cannabis. 4. I waive my right to grow
I agree with all the Terms and Conditions above.
Previous
Next
Submit
Press
Enter
17
Cardholders Signature
By signing, I agree to the charge for the above stated and requested service.
Clear
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
17
See All
Go Back
Submit
