EmailMe Form - Product Listing Form

We will only consider medicine that is completely organic, free of mold, pests, pesticides and any foreign matter. MUST BE CLEAN !!
We do encourage and respond to patient feedback, for quality control.
You will receive a notice of any and all feedback, concerning your product/s.
Too many complaints may be cause for termination of your product listing.

After you submit this form:
You will receive a verification email and invoice, requesting payment.

Once we have received your payment for product listing:

A. Your product will be placed on our website menu, within 48 hours.

B. After placement on website, you will again receive a email with a, "Test Order Form", as if made by ordering patient.
This is only to verify all information and settings are correct.

When orders for your product are made:
We confirm and verify all information.
The Patient receives an invoice of their order, with instructions for your payment.
Then you will receive an email containing all information listed below.

1. Patient Last Name
2. Product Ordered
3. Quantity Ordered
4. Total Cost $
5. Preferred payment method

Image of Medical Cannabis Rec. and Valid Photo ID, are retained by our office for 60 days.

It is your responsibility to facilitate any further transaction.
A courier will be assigned, an appointment made to pick up products twice a week.

We do solicit and encourage feedback from patients.

Click above to read Policies & Protocol

Name *

First Last

Email *

Medical Cannabis Documentation / Certification

Product Name *

Product type *

Test Results Documentation

Additional Product Information

Quantities offered and acceptable donation. *

7 grams $
14 grams $
1 ounce $
2 ounces $
4 ounces $
8 ounces $
1 unit $
2 units $

Put the number "00" for quantities not offered.

Product Photos: *

Good photos, will increase response.

Start up fee *

Product listing $40.00

This is a ONE TIME ONLY fee for adding product to menu.

30 day listing *

30 days $35.00

60 days $55.00

90 days $85.00

Click all regions below that you service.

State you service? *

Zip Codes Serviced *

Seperate 5 digit zip codes, with comma.

Payment Forms Accepted

List all Banks, financial Institutions or methods of payment you will accept.
The more options you offer, the greater the success.

Order Payment Methods you will accept? *

Other forms of payment that you will accept?

Every Order Placed

The ordering patient receives an instant autoresponse copy of their order.

If you desire, we can add an autoresponse, that also includes your payment instructions.

Email for orders to be sent to: *

This email is where orders are sent.

Confirm

Pay to the order of: *

First Last

Payment Instructions:

P.O. BOX
Details
Needed information.
ETC. *

This autoresponse also includes a request for the patient to include a copy of their order with their payment.