Schedule an Appointment

We will call you to schedule an appointment if you'd like to fill out the form below, or call our business office at 855-420-8100 (toll free) Monday - Friday between 8:30am - 4:30pm. Based in Kalamazoo, the business crew answers ALL calls.

Appointment Request



(data fields with an asterisk * are required)

I am seeking a new card
I am seeking to renew a card


Which of our clinics are you interested in visiting?

Kalamazoo
Grand Rapids
Battle Creek


Personal Information

Name:
*

E-mail:
*

Confirm E-mail:
*

Daytime Phone:
*

Address:


City:


Zip:



Legal Status/Medical Information

Do you have marijuana related legal issues pending? *

No   Yes

What is your MMMP qualifying condition?



How will you provide copies of your medical records:

I will bring copies with me
I will have my records FAXED
I have no records


How did you hear about us?




Question or comments



Enter the code as it is shown (required):

I have read the Patient Privacy Notice *