EmailMeForm
COMP Membership Application
Compassionate Membership Program.
Valid for:
1. AIDS/ HIV
2. Alzheimers
3. Anorexia
4. Cachexia
5. Chemotherapy Patients
6. Crohn's
7. Epilepsy
8. Fibromyalgia
9. Glaucoma
10. Hepatitis C
11. Hypertension
12. MS
13. Peripheral neuropathy
14. PTSD US Military Combat Veterans.
15. Seizures
16. Sickle cell
17. Sleep Disorder
18. Tourette's
19. Ulcerative colitis
This information is seen by only one person,
(Chief Executive Volunteer)
This information is destroyed, upon confirmation by your doctor. (Will hold up to, 30 days. Pending confirmation)
Name
*
First
Last
Email
*
Confirm
Verify your applicable diagnosed illness.
*
Aids / HIV
Alzheimers
Anorexia
Cachexia
Chemotherapy
Crohns' Disease
Epilepsy
Fibromyalgia
Glaucoma
Hepatitis C
Hypertension
Multiple Sclerosis
Peripheral neuropathy
PTSD US Military Combat Veteran
Seizures
Sickle cell
Sleep disorder
Tourette's
Ulcerative colitis
State issued photo identification
*
Medical cannabis certification.
*
Documentation, or certification, of illness & diagnosis.
*
Please provide any form of documentation, or physicians statement.
DD-214
US Military "COMBAT" Service
Must accompany physicians diagnosis of PTSD
Physician's Name, or the Name of Practice
*
Physician's city and state of Practice
*
We can not provide medicine without verification by your physician.
You must inform your physician, authorizing our pending inquiries, of your condition and status.
We will allow up to 30 days for verification.
*
Yes, I understand
Do we have your authorization to contact your physician for verification of these facts?
*
Yes
IF APPROVED
1. You will be contacted by email.
2. You will be added to our Comp Members Club, for 6 months.
4. You may use, "Members Order Form"
You must reapply every 6 months to renew.
You will receive an invoice of your order if approved.
May take up to 24 hours for first time patients.