Patient Assistance Application

Patient Assistance Application

We will NEVER share your information with anyone at anytime! If you do not feel comfortable filling out this form online, please call one of our counselors at 602-903-802, we would be happy assist you offline!
Full Name*

First NameLast Name
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Annual Income*
Please Provide Household Income After Taxes
# in Household*
# of People Living in Your Household
Are You Currently on Public Assistance

YesNoApplication in Process
I am a U.S. Citizen

YesNoOther
Do You Currently Have an MMJ Card

YesNoExpiredRecently Applied
If Yes, Which State
Please Provide a Copy of Your MMJ Card (If Applicable)

Upload a File

Cancelof
Please List Your Current Medical Conditions*
Are You Currently Using Cannabis?
What Barriers Have You Faced Accessing Cannabis?
What Are Your Primary Needs?

Obtaining an MMJ CardCost of Monthly MedicationTransportation to Dispensary or MMJ DrMedication Consultation (Reviewing Strains, How to Medicate, Safe Medication Storage)Other (Please Make Request Below)
Other Need
Additional Information
Please provide any additional information you feel might be relevant.
How Did You Hear About Us?

Cannabis Access Alliance WebsiteHigh Times MagazineBlog or New ReaderInternet SearchSocial Media (Facebook, Instagram, Twitter, etc)Other
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