Schedule Appointment for Pain Specialist Marijuana Doctor

First Name

Middle Name

Last Name

Date of Birth

If you are under 18 years of age you must have your parent fill out the form under their name

Medical Condition

If more than one medical condition applies then select the medical condition that you are most interested in receiving cannabis treatment for. Additonal medical conditions may be added at a later time.

If cancer, please specify type

Physical Address

You must have a New Mexico address to enroll in the Medical Cannabis Program

Street Address 1

Street Address 2

City

State

You must have a New Mexico address

Postal Code

County

Type and select county

Contact Info

You must enter at least one phone number below.

Home Phone

Office Phone

Mobile Phone

Send text message updates

Check the box above if you would like to receive text message updates to your phone about coupons and specials from dispensaries

Questionnaire

Do you plan on growing your own cannabis?

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How did you hear about us?

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