Complete the form below if:

• You want to apply for your Medical Marijuana Card
• You are already an Approved Patient who is looking for a Caregiver or Grower
• You are a Caregiver / Grower who is looking for a patient.

Questions? Call 480-420-8983

One of our friendly staff can be reached via phone for Medical Marijuana Doctor scheduling to get a Medical Marijuana Card, or to match Medical Marijuana Patients and Medical Marijuana Caregivers / Growers with qualified patients.

All information is kept private and confidential, unless you authorize release.

First Name:
Last Name:
City:	Zip:
Email:
Phone	() - Ext. Can we text this number?
Alt Phone	() - Ext. Can we text this number?
Best Time To Contact You:
Date of Birth:	- - (DD-MM-YYYY)
Referred By:
Questions / Comments:

I want...
	To get my Medical Marijuana Card
I am already an Approved Medical Marijuana Patient and...
	I Am Looking for a Caregiver / Grower
	Yes the Arizona Medicinal Network has permission to share my information with Caregivers
I am a Caregiver / Grower...
	I am looking for a patient in need
	Yes the Arizona Medicinal Network has permission to share my information with patients.