Please send a clear image/photo copy of your "Doctor's Recommendation" & "Valid CA Driver's License" to Unclear images will be rejected without notice.

Patient Name *
Patient Name
Valid CA Driver's License #. Must be over 21+
Date of Birth *
Date of Birth
Must match same date as CA D/L
Patient's Address *
Patient's Address
Patient's current address
List anything you would like us to know about you. Food allergies, favorite activities, foods you would like to see, your favorite entertainment, creative art, things you would like to do, etc...