Pre-Qualify Schedule Visit Get Recommendation PreQual Name* First Middle Last Email* Date of Birth** If you are under 18 years old consent from your other physician is required. Date Format: MM slash DD slash YYYY Phone*Do you have proof of Florida residency?*See examples of acceptable proofs for residency here.YesNoPlease check all of your conditions listed below that you think may benefit from medical marijuana use for a physician’s review.*In order to qualify, the condition has to be severe enough to be considered debilitating or terminal. By definition, debilitating, adj: something that seriously affects strength or ability to carry on with regular activities. HIV / AIDS ALS Cancer / Tumor Cerebral palsy Dialysis Crohn's Disease / Inflammatory Bowel Disease Degenerative joint disease Diabetes, with associated neuropathy or vision issues Epilepsy / Seizures Fibromyalgia Glaucoma Herniated disk Hepatitis, Cirrhosis Lupus Multiple sclerosis Condition leading to muscle spasms Muscular dystrophy Myasthenia Gravis Neuropathy Osteoarthiritis Osteoporosis, with compression fractures Polymyalgia rheumatica Post-Polio syndrome Parkinson's Disease Severe peripheral vascular disease PTSD Reflex sympathetic dystrophy Restless leg syndrome Rheumatoid arthritis Scoliosis / Bone deformity Spinal stenosis TMJ syndrome Trauma or surgical complications Depression Anxiety Other condition not listed Have you received previous medical treatment for your condition?*YesNoSubscribe to Newsletter Yes CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
