New Patient Verification

If you are a new patient and would like to get verified with our dispensary please fill out the form below. You will be notified as soon as we have verified your information.

We can be reached via phone at : 760-898-1990

Your Name

Your Email

Your Phone

Doctor's Name

Doctor's Clinic Name

Verification Website

Verification Phone Number

Recommendation Date

Recommendation Expiration Date

Recommendation #

 I agree to your terms & conditions.