Pre-register

1. PERSONAL INFORMATION
2. Name(required)
3. Email Address(valid email required)
4. Phone
5. Birth Date
6. DRIVER LICENSE
7. ADDRESS:
8. CITY:
9. Zip Code
10. DOCTOR'S INFORMATION
11. DR. NAME:
12. DR. PHONE
13. RECOMMENDATION NUMBER
14. DATE OF RECOMMENDATION:
15. DATE OF EXPIRATION:
16. Recommendation/ID Upload:
17. REFERRALS
18. REFERRED BY: WeedMaps CA NORML Myspace Facebook Online Forum Other
19. - If Website - URL:
20. - If Referrer Patient - Name
21. - If Referrer Patient - Email:
22. - If Other - Comments:
23. membership plan interested in: White - $0.00 Black - $45.98 Silver - $87.98 Gold - $160.92 Green - $294.26 Diamond -$1057.48

 

Once you submit your Pre Registration

We Will Verify That you are a Patient

and a

MedCare Representative will give you a call

Or

Give us a call at 800-420-4369

or Email us at MedCare@MedCare420.com