AZ Mesa Online Patient Certification

1
Name* This field is required.
First Name
Last Name
2
URLPrefill URL
3
Date of Birth* This field is required.Please enter your date of birth.
Date
Month
Day
Year
4
Email* This field is required.
example@example.com
5
Phone Number* This field is required.
Area Code
Phone Number
6
How did you hear about us
7
Signature* This field is required.PLEASE E-SIGN SIGNATURE: I Certify that I am not seeking Marijuana for illegal purposes; I am not a reporter or other member of the media working a story; And, I am not a member of law enforcement seeking to investigate or build a case against my physician or anyone affiliated with my physician.
8
Did you have a Medical Marijuana Card before, if yes please provide the number.
9
Have you been experiencing Chronic Pain for 12 months or more?* This field is required.
Yes
No
10
What part of the body are you experiencing your chronic pain?* This field is required.
11
Using the scale 1 to 10 select what your pain level is?* This field is required.
12
How long have been experiencing the pain?* This field is required.
13
Are you currently nursing or pregnant?
YESNO
14
PLEASE E-SIGN SIGNATURE THE SAME WAY YOU SIGNED YOUR DRIVERS LICENSE OR STATE IDENTIFICATION CARD FOR THE STATE. PLEASE E-SIGN Patient Attestation : 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.
15
Please take a Clear Full Photo of your Arizona Identification Card/ Drivers License or US Passport
16
Please take a full headshot Photo of yourself with no hat, or sunglasses with a plain wall background for your MMJ Card Photo
17
Physician Consultation* This field is required.This includes office fees and physician consultation once you receive the recommendation, an application fees of $150 need to be paid to Arizona Department of Health Services for issuance of your medical card (If you qualify for food stamps you may receive AZDHS discount and need to pay only $75).
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ORDER SUMMARY
Service FeesUSD
SubtotalUSD
Total costUSD
Medical Marijuana RecommendationArizona Medical Marijuana Card evaluation only
$125.00Edit
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18
Invoice ID
19
Mailing Address (Only fill if different than billing address)This will used by AZDHS for your medical card.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
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United Kingdom
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Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
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Western Sahara
Yemen
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Zimbabwe
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