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2
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3
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4
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5
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Birth Date* This field is required.
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Do you live in one of the following states?* This field is required.Alabama Arkansas Colorado Connecticut Delaware District of Columbia Florida Idaho Illinois Indiana Kentucky Maryland Nebraska New Hampshire New York North Dakota Minnesota Mississippi South Carolina Tennessee Texas Utah Vermont Washington West Virginia Wisconsin Wyoming
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8
Please enter your preferred language below. (optional)
9
What medical condition or symptom is prompting you to apply for a medical cannabis card?* This field is required.Please refer to your state specific website for qualifying medical condition
10
How long have you been experiencing this medical condition or symptom?* This field is required.
11
Please upload a copy of front and back of your drivers license or passport* This field is required.
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Some states require patients to have a bonafied relationship with a provider before a card can be issued. If you reside in one of those states, and two visits are required, do you plan to use Self-Pay or Insurance for your initial visit?* This field is required.
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Insurance
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13
Please upload a copy of you insurance card front/back
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Admin Fee* This field is required.A $75.00 is required for providers to initiate this request. Reach out to our team if you have questions/concerns with this amount.
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Before you finish this form, we wanted to share the exciting news. My Virtual Physician now has its own app. Available now on Android phones/tablets from the Google Play Store. Click here to download:

https://play.google.com/store/apps/details?id=com.lifehealthwalletusa.lifehealthwalletusa&hl=en&gl=US
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Signature* This field is required.I attest that I will not divert marijuana to any individual who or entity that is not allowed to possess marijuana pursuant A.R.S. Title 36, Chapter 28.1 and that the information provided in the application is true and correct.
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