Alternative Care Clinics - Southern California
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Let's Get Started - Pre-Qualify

Want to see if you pre-qualify? Fill out the form below and see if you qualify. This survey is COMPLETELY CONFIDENTIAL and will not be shared or sold to ANYONE.

First Name / Last Name
Date of Birth
Month
Day
     Year
Phone Number
Email Address
Do you have a valid California ID?
Do you have a medical condition that could benefit from the use of cannabis? (AIDS, Cancer, Migraines, Glaucoma, Asthma, Chronic Pain, Multiple Sclerosis, Nausea, Insomnia, depression, Anxiety, Anorexia or other serious illnesses)
Have you been previously diagnosed for your condition?
Do you have any medical paperwork to support your diagnosis?
(X-rays, MRI’s, physician letters, diagnosis or any other documentation showing that you have been to a doctor and have been diagnosed with your condition. )
Do you have the name and contact information for your primary care physician and can you provide that information at the time of your appointment?
Are you currently on probation or parole?
Have you read our privacy policy?
Which clinic location would you prefer to be evaluated?
Comments / Questions

 

If you would like assistance with getting a copy of your medical records and have seen a doctor within the last year, you may download our medical release form that is listed below.

Please provide us with as much information as possible when filling out the medical release form, sign, date, and fax it back to us upon completion. After we receive your completed release form, we will forward this request to your doctor's office.

Assistance with obtaining a copy of your medical records from your primary care or treating physician's office is an extra and complimentary service we provide to our patients. Nonetheless, some doctor's office may charge a fee to obtain a copy of the patient's medical records. If this occurs, the patient would be responsible for any fees imposed by the corresponding doctor's office.

If you do not have sufficient medical records at the time of your visit, it is possible that you may not receive a recommendation to use cannabis during your initial visit. The doctor will ask you to come back for a follow up visit, at no additional cost, once your records arrive.

Alternative Care Clinics Release Form



* All emails will be strictly confidential

 
 
   
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