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Do you have an Arkansas State Identification? *

Yes

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address *

City *

State *

Postal code *

Do you have a history of tobacco use? *

Yes

Do you currently use tobacco? *

Yes

Are you currently taking any medication? *

Yes

Please list any medication you are currently taking *

Select your qualifying condition *

Cancer
Glaucoma
HIV/AIDS Positive Status
Hepatitis C
Amyotrophic Lateral Sclerosis
Tourette's Syndrome
Crohn's Disease
Ulcerative Colitis
Post-Traumatic Stress Disorder
Severe Arthritis
Fibromyalgia
Alzheimer's Disease
Cachexia or Wasting Syndrome
Peripheral Neuropathy
Intractable Pain, which is pain that has not responded to ordinary medication, treatment, or surgical procedures for more than six (6) months
Severe Nausea
Seizures including without limitation those characteristic of epilepsy
Severe and persistent muscle spasms including without limitation those of multiple sclerosis
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Has your pain been ongoing for six months or longer? *

Yes

Unfortunately pain must be ongoing for six months or longer to qualify as chronic pain. Please choose a different Diagnosis on the next screen

Please Choose from the following *

I will upload documentation of my PTSD

I will take the FREE PTSD self test to serve as documentation of my PTSD

I have already taken the free PTSD Self Test

Do you have documentation of your qualifying condition? *

Yes

Please provide a detailed description of the medical history surrounding your condition(s). Try to be as specific as possible and include the time frame your condition began. *

I certify that the information provided here is true, and accurate to the best of my knowledge *

Yes

Upload patient history documentation or photographs of medications *

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Terms and Conditions

I have read and agree to the terms and conditions *

Yes