Medical Marijuana New Patient Application

Please fill out all information as it appears on the ID you will be uploading, the State goes off of that. They do not accept nicknames, shortened names, or any other name. ***UPLOAD ALL NECESSARY FORMS AT THE END OF THE FORM***

Patient Intake

How did you hear about us?

First Name *

Middle Name

Last Name *

Suffix

Date of Birth *

Email Address *

Gender *

ID Type *

ID Number *

Issuing State *

Issue Date *

Contact Information

Are you Homeless ?

Street Address *

City *

State *

ZIP / Postal Code *

County *

Phone *

Check if mailing address is different than residence address

Street Address

City

State/Province

ZIP / Postal Code

Emergency Contact Name: *

Emergency Contact #: *

Caregiver Information

Do you want to designate a caregiver?(Extra $200 state fee) Needed for Minors under 18, or Patients that need help obtaining Meds

Caregiver Full Name:

Caregiver Date of Birth:

Street Address

City

State/Province

ZIP / Postal Code

Request to Cultivate?

Are you requesting to cultivate?MUST LIVE 25 AIR MILES AWAY FROM A LICENSED DISPENSARY

Approval to cultivate will not be granted without a valid residential address that meets the requirements to cultivate.

Other Info

Clinical Studies

Would you like to be notified of clinical studies?

SNAP Eligibility

If you are eligible for SNAP assistance and proper documentation is provided, your application fee will be reduced from $150 to $75.

Are you eligible for the Supplemental Nutrition Assistance Program (SNAP)? *

Patient Signature:

Date Signed: *

Upload SNAP CARD OR DOCUMENTATION

No file chosen

Upload SNAP CARD WITH YOUR NAME EMBOSSED ON THE FRONT OR CURRENT AWARD LETTER

Upload ARIZONA DRIVER LICENSE, ARIZONA I.D, OR U.S PASSPORT

No file chosen

Upload IMAGE HERE

No file chosen

Please upload a forward facing headshot here. You cannot have any head objects on, or masks. The State is very picky when it comes to the photos, if you have any questions please call us. 520-323-0069

Upload MEDICAL CURRENT RECORDS (IF NEEDED)

No file chosen

Upload your Current Medical Records here, if needed. If we already have your medical records, or if you are sending them another way, we do not need you to upload anything.

Thank You for your submission

Thank your for your submission. Somebody will be reaching out to your soon.

Dr. Sonya Johnson

Dr. Aiyana Brown

Home Page

Medical Marijuana Page

Shop CBD Here

Make an appointment today

Disclaimer

Naturopathic Doctor Visit Insurance Reimbursement Disclaimer:
Natural Healing Care Center currently does not accept insurance for naturopathic services. However, we can assist with out-of-network deductions by providing an ICD Code for a New Patient Problem Focus Exam. By providing the insurance company with the ICD Code, it will allow them to deduct full or partial costs depending on the financial policies of the provider. The patient may personally contact their insurance company to inquire if they can accept the following ICD Code listed below.

ICD Code:
99201

Additional Reimbursement Options:
At the time of the naturopathic visit, NHCC will provide each patient with an itemized receipt of the services rendered, which the patient can provide to their insurance company for full or partial reimbursement. If there are any additional inquiries or questions involving insurance or coverage or about our licensed naturopathic physicians, please contact the NHCC office directly!