I am: *

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? *

Yes

No

Birth Date *

First Name *

Last Name *

Phone *

Email *

Address *

State *

City *

Postal code *

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 *

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 *

How did you hear about us?

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How did you hear about us? *

Terms and Conditions

I have read and agree to the terms and conditions *

Yes

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