Qualify

Please fill out the form below to pre-qualify for the Arizona Medical Marijuana Program. Once you submit the form, our physicians will review your information and our admin personnel will respond via email with results. Thank you for choosing United MMC.

First Name *

Last Name *

Email *

Phone *

What is the primary debilitating condition that you suffer from? *

Please describe the primary condition below. Also include any secondary condition that you may suffer from.

How long have you had this condition? *

Have you seen a previous doctor for this condition?

Approximately when was your last doctor visit?

Please describe below any special circumstances regarding your condition or conditions. How does your condition contribute to your day-to-day life. What do you hope to gain from using this form of treatment to treat your condition.

This pre-qualification form will be reviewed by the doctor. Below you can type any questions or concerns that you may have using this as an alternative medication.

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Clinic Hours are 10:00am – 5:00pm Monday – Friday