This recommendation is for California patients only. If you need a recommendation for another state, please visit OnlineMedicalCard.com and select "Other States" in the top menu. Doctors are licensed by individual states only. If you choose the wrong state you will not be issued a refund.
Check each medical problem that you suffer from or select other to have the doctor evaluate your unique condition. At least one box must be checked to qualify.
In order to verify your legal name and identity, you must upload a government-issued photo ID card such as a driver's license or passport.
By electronically signing this document, you declare that the information on this form is true and correct.
Additionally, you are also aware that your recommendation may be revoked at any time if you misrepresented yourself on this form.
Note: Filling out this questionnaire does not guarantee a medical marijuana recommendation.
I give my consent to telemedicine.
(Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care.)
I declare the following to be true:
Use your mouse, finger or stylus to add your signature.