Register

Patient Information

Name

Address

City
Zip

Phone
Email

Date of Birth

Drivers License Number

Upload your CA State ID

Medical Information

Upload your Doctor's Recommendation

Patient ID Number

Doctor's Name
Doctor's Medical License Number

Doctor's Verification Number/Website

Expiration Date of Recommendation

Questions, Comments and Special Requests

Is it okay to contact you with info on specials and new strains?
By submitting this registration form you agree to our Minimum Age Requirement and Privacy Policy
I am at least 18 years of age. All information that is entered here is completely private and will not be shared with anyone. Your email address will not be sold or shared with anyone outside of our Cooperative. Maintaining your privacy is our number one priority. All available items are not for resale.