QUALIFY - Arkansas Medical Cannabis Network

Name *

First

Last

Email *

Phone *

Date of Birth *//

City / State *

Please select your qualified diagnosis: *

I understand that Arkansas Medical Cannabis Network is NOT a dispensary and does NOT carry, sell, or distribute marijuana or any products of any kind *

Yes, I understand

I understand that I must be at least 21 years old and have proof of Arkansas residency *

Yes, I understand and can provide a valid Arkansas Driver's license or state-issued photo ID

Do you have clinic/hospital paperwork showing your name and qualified diagnosis? *

No, but I will request the appropriate documents and bring them to my appointment or fax them to 501-500-4123 prior
Yes, and I will bring these documents to my appointment. I understand that failure to provide documentation of a qualified diagnosis will prevent the ability for the physician to certify my application

How did you hear about us? *

Do You Qualify?