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. Or for faster service you can text your information and place your order at 760-660 5579.

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.