New Member Online Form

New Member Package
All new members receive a welcome gift from Express Medz!

It’s as easy as 1-2-3…

  1. Review the Medication page, call us or use the form below.
  2. Elect to have the driver collect copies of the following OR scan or take a clear picture of them and email to:
    • CA ID, CA drivers license or out of state ID with proof of residency.
  3. Agree to the Express Medz Terms of Service that will be emailed to you.
That’s it!
Stand by and an Express Medz representative will call you within 30 minutes of verification during normal business hours (see home page Hours of Operation).

Please note: Medical Records are optional

Your First and Last Name (required)

Your Email (required)

Mailing Address (required)

Phone Number (required)

Date of Birth (day/month/year) (required)

Confirm that you are 21 years or older and a California Resident

 I am 21 Years or Older California Resident

Referring Doctor's Name (optional)

Referring Doctor's Contact Phone Number (optional)

Doctors ID Number (optional)

Referring Doctor's Website (optional)

Patient ID Number (optional)

Doctor Referral Date: day/month/year (optional)

Doctor Referral Expiration Date: day/month/year (optional)

California ID or Drivers License Expiration Date

Your First Order

Delivery Street Address, City and Zip

Nearest Cross Street & Additional Instructions (if necessary)

Delivery Date (day/month/year)

Preferred Delivery Time

Mobile Number to send delivery confirmation messages

Do you mind telling us for what medical reasons do you use Medical Marijuana?

Are you affiliated in any way with local, State, or Federal Law Enforcement?

 No Yes

How did you hear about us? And let us know if there are other things you would like us to carry..

By clicking the "Send" button, I agree to Express Medz Terms of Service (Dispatch will confirm delivery of this)