If you would like to share some details about your health to get a head start on our application process please complete this form.  This step is completely optional.  This information will help us evaluate your situation to determine if we think we can help.  If we can help, the information will be used to create a customized plan for your pharmaceutical and cannabis care.  Please note that we are selective on who we can accept into our care due to resource limitations at this time.  We will only accept a patient if we believe we can make a difference.