Who Sponsored You Into CannaSense?*Please indicate either the full name or code of your sponsorYour Name* First Last Enter Email Address* Enter Email Confirm Email Phone*Please enter the best number to reach you. Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Create Your Username*This will be used to login into Apothecary once all your documents have been verified. No emails please, may contain letters and numbersWhat Part of CannaSense Are You Interested In?*PatientCaregiverMemberAre You 18 Years or Older?*YesNoAt this time CannaSense is only able to work with adults. If you or someone you know has a child who needs medical cannabis please call our office.Do You Agree to the Terms of Service?*YesNoUPLOAD GOVT ISSUED PHOTO ID* Drop files here or Can be any government issued ID, such as a Driver's License or Passport. Please remember that the file size cannot exceed 64MB.Get Recommendation or Upload current Recommendation: Doctor's visit will cost $69.99 with a $4.20 discount:UPLOAD YOUR DOCTOR RECOMMENDATION BELOW*(NOTE: DO NOT SUBMIT THIS FORM WITHOUT YOUR RECOMMENDATION IF YOU ARE GOING TO BE A PATIENT/MEMBER. Detailed Instructions Can Be Found on the Become a Member Page. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.