Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Must be a residence. Cities include (but are not limited to): Martinez, Pacheco, Rodeo, Hercules, San Pablo, Richmond, Vallejo, Benicia, Pleasant Hill, Concord, Pittsburg, Antioch, Oakley, Brentwood, Walnut Creek, Orinda, Alamo, Danville, and San Ramon.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Patient? *

If you're a new patient, please make sure to have a picture of your recommendation and ID ready to go. You must send a photo via text or email before your order is confirmed.

I have my valid medical recommendation and ID

I don't have my medical recommendation, but I will get one so I can place an order!

Time *

Must be at least 2 hours in advance! Thank you :)

Hour

Minute

Second

AM PM

Date *

MM

DD

YYYY