I am:
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Seeking my Arkansas Medical Marijuana Certification for the First Time
Renewing my Arkansas Medical Marijuana Certification
Please Use The New Patient Form
Are you a returning patient of AR MMJ Cards, Dr. Daniel, or Concierge Clinics LLC?
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Yes
No
Patient First Name
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Patient Last Name
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Preferred Name
Phone
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Email
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Address
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State
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City
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Postal code
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Birth Date
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Gender
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Male
Female
Other
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Do you currently use tobacco?
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Yes
No
Do you have a history of tobacco use?
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Yes
No
Are you currently taking any medication?
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Yes
No
Please list any medication you are currently taking
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Select your qualifying condition
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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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Please Upload a picture of your certification from last year to serve as your documentation. If you do not have a your certification from last year, please upload a picture of your mmj card
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How did you hear about us?
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Google
Facebooks
Instagram
Twitter
Weed Maps
Satisfied Customer
Other
How did you hear about us?
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Terms and Conditions
I have read and agree to the terms and conditions
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Yes