New Patient Registration

Patient Information

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Are you a first time cannabis user? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What type of meds do you prefer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Can ANC text you with specials? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Can ANC email you with our specials? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How can we help you today? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you ACTIVE DUTY military or Veteran? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you were referred by another patient, please provide their full name.

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Patient Agreement

  • I acknowledge and agree ANC will provide me with Patient Handbook at my request.

  • I understand my agreement to comply with rules of the dispensary and code of conduct

  • I acknowledge and agree ANC will not render medical advice or conduct any medical procedures, but, instead, will only provide access to medical marijuana in accordance with the Laws in the State of Arizona.

  • I agree to immediately report in writing to ANC any events or circumstances related to the dispensary that I reasonably believe to be a violation of laws governing medical marijuana, or create an unsafe condition or environment in or about the dispensary, which could have a detrimental impact on members of ANC.

  • I agree to indemnify and hold ANC and its affiliates harmless from any costs or damages I might incur as a result of my failure to perform my obligations under this agreement. It is my sole responsibility to read the Patient Handbook and Information made available to me today.

  • Electronic mail (email) and text messaging are forms of communication that may be used between
    you and Arizona Natural Concepts (ANC). We want to make sure you know that unencrypted email and text communications are not secure communications. ANC is not able to encrypt text or email messages.

    If you elect to communicate from your workplace or a public computer, you should be aware that your employer and other agents might have access to email communications between you and ANC. Email and text communications may become a part of your patient record and be accessible to support staff as needed for our operations.

    Incoming email communications will be reviewed and answered as soon as possible. If you have not heard from ANC with a response and are concerned that your message was not received, please call the dispensary during regular business hours. EMAIL COMMUNICATION SHOULD NEVER BE USED IN THE CASE OF AN EMERGENCY OR FOR URGENT REQUESTS FOR INFORMATION.

    ANC may use autodialed texts for any purpose including marketing to the number I provided. I understand that consent is not required for purchase. Periodic messaging. Text STOP to stop (confirmation text will be sent) and HELP for help. Not all carriers covered; msg & data rates may apply. ANC will limit information sent via text message to the minimum necessary. I understand that my information will be used as described here and in the attached Privacy Policy and I agree to the Terms. This constitutes my digital signature.


    This authorization may be revoked at any time and must be done in writing. It is understood that the revocation will not apply to information that has already been released based on this authorization.

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New Patient Registration

New Patient Registration

Patient Information

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Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you a first time cannabis user? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What type of meds do you prefer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Can ANC text you with specials? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Who is your Cell Phone Provider? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Can ANC email you with our specials? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How can we help you today? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you ACTIVE DUTY military or Veteran? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How did you hear about ANC Dispensary? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Agreement

  • I acknowledge and agree ANC will provide me with Patient Handbook at my request.

  • I understand my agreement to comply with rules of the dispensary and code of conduct

  • I acknowledge and agree ANC will not render medical advice or conduct any medical procedures, but, instead, will only provide access to medical marijuana in accordance with the Laws in the State of Arizona.

  • I agree to immediately report in writing to ANC any events or circumstances related to the dispensary that I reasonably believe to be a violation of laws governing medical marijuana, or create an unsafe condition or environment in or about the dispensary, which could have a detrimental impact on members of ANC.

  • I agree to indemnify and hold ANC and its affiliates harmless from any costs or damages I might incur as a result of my failure to perform my obligations under this agreement. It is my sole responsibility to read the Patient Handbook and Information made available to me today.

  • Electronic mail (email) and text messaging are forms of communication that may be used between
    you and Arizona Natural Concepts (ANC). We want to make sure you know that unencrypted email and text communications are not secure communications. ANC is not able to encrypt text or email messages.

    If you elect to communicate from your workplace or a public computer, you should be aware that your employer and other agents might have access to email communications between you and ANC. Email and text communications may become a part of your patient record and be accessible to support staff as needed for our operations.

    Incoming email communications will be reviewed and answered as soon as possible. If you have not heard from ANC with a response and are concerned that your message was not received, please call the dispensary during regular business hours. EMAIL COMMUNICATION SHOULD NEVER BE USED IN THE CASE OF AN EMERGENCY OR FOR URGENT REQUESTS FOR INFORMATION.

    ANC may use autodialed texts for any purpose including marketing to the number I provided. I understand that consent is not required for purchase. Periodic messaging. Text STOP to stop (confirmation text will be sent) and HELP for help. Not all carriers covered; msg & data rates may apply. ANC will limit information sent via text message to the minimum necessary. I understand that my information will be used as described here and in the attached Privacy Policy and I agree to the Terms. This constitutes my digital signature.


    This authorization may be revoked at any time and must be done in writing. It is understood that the revocation will not apply to information that has already been released based on this authorization.

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