I am:
*
Seeking my Arkansas Medical Marijuana Certification for the First Time
Renewing my Arkansas Medical Marijuana Certification
Are you a returning patient of AR MMJ Cards, Dr. Daniel, or Concierge Clinics LLC?
*
Yes
No
Patient First Name
*
Patient Last Name
*
Preferred Name
Phone
*
Email
*
Address
*
State
*
City
*
Postal code
*
Birth Date
*
Gender
*
Do you currently use tobacco?
*
Yes
No
Do you have a history of tobacco use?
*
Yes
No
Are you currently taking any medication?
*
Yes
No
Please list any medication you are currently taking
*
Select your qualifying condition
*
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
*
How did you hear about us?
*
Google
Facebooks
Instagram
Twitter
Weed Maps
Satisfied Customer
Other
Terms and Conditions
I have read and agree to the terms and conditions
*
Yes