Patient Application Not Approved Please leave this field empty. First Name * Last Name * Date Of Birth * Gender * malefemaleother ADDRESS Street Address * Street Address Line 2 City * State ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoGeorgiaHawaiiIdahoIllinoisIndianaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMontanaNebraskaNevadaNew HampshireNew MexicoNorth CarolinaNorth DakotaOregonSouth CarolinaSouth DakotaTennesseeTexasVermontWashingtonWisconsinWyomingConnecticut Postal Code * Phone Number * Email * Please select your conditions: * Agitation Of Alzheimer’s DiseaseAids Or HivAlzheimer’s DiseaseAmyotrophic Lateral Sclerosis (Als)AnorexiaAnxietyAnxiety DisordersArthritisAustismAutismBipolar DisorderCachexiaCachexia (Or Wasting Syndrome)CancerCerebral PalsyChronic Inflammatory Demyelinating PolyneuropathyChronic MigrainesChronic Pain (Lasting Longer Than Six Months)Chronic PancreatitisChronic Traumatic EncephalopathyComplex Regional Pain Syndrome (Type 1-2)Corticobasal DegenerationCrohn’s Disease Or Ulcerative ColitisCystic FibrosisDecompensated CirhosisDepressionDyskinetic And Spastic Movement DisordersDysmenorrheaEhlers-danlos Syndrome (Caused By Chronic Pain)End Of Life Care (Terminal Illness)Epilepsy And Other Seizure DisordersFibromyalgiaGlaucomaHepatitis CHiv / AidsHuntington’s DiseaseHydrocephalus (With Intractable Headache)Inflammatory Bowel Disease (Including Colitis And Crohn’s)InsomniaInterstitial CystitisIntractable And Uncontrolled Seizure DisorderIntractable EpilepsyIntractable Neuropathic Pain (Unresponsive To Conventional Treatments)Intractable PainIntractable SeizuresIntractable SpasticityMedian Arcuate Ligament Syndrome (Mals)MigraineMultiple Sclerosis (Ms)Muscle SpasmsMuscular DystrophyNail-patella Syndrome (Nps)NauseaNausea And Severe VomitingNeurodegenerative DiseasesNeuropathic Facial PainNeuropathiesNeuropathyOpioid AlternativeOpioid DependencyOpioid-use DisorderOsteogenesis ImperfectaOther ConditionParkinson’s DiseasePeripheral NeuropathiesPersistent Muscle Spasms (Including Spasms Caused By Conditions Like Epilepsy And Multiple SclerosisPersistent Severe NauseaPost Herpetic NeuralgiaPost-laminectomy Syndrome With Chronic RadiculopathyPost-traumatic Stress Disorder (Ptsd)Rheumatoid ArthritisSeizure DisordersSeizuresSevere And Chronic PainSevere And Persistent Muscle Spasms, Including But Not Limited To Those Characteristic Of Multiple SclerosisSevere ArthritisSevere Chronic/intractable PainSevere NauseaSevere Psoriasis Including Psoriatic ArthritisSickle Cell AnemiaSickle Cell DiseaseSpasticitySpinal Cord Damage (Neurological Pain Or Intractable Spasticity)Spinal Cord Disease Or InjurySpinal Cord Injury With Intractable Spasticity (Irreversible)Terminal IllnessTourette’s SyndromeTraumatic Brain InjuryUlcerative ColitisVulvodynia And Vulvar Burning SymptomsWasting Syndrome Other Condition* Please upload your State ID How did you hear about us? * GoogleBingYahooBaiduAskAOLDuckDuckGoYandexOther Search EngineNewsInternetWord Of Mouth
