New Patient Certification

Legal First Name

Legal Last Name

Telephone Number

Email Address for State Registration

Create a Password for State Login

SSN

Date Of Birth

Street Address

City

State

Zip Code

County

Please provide a detailed description of your qualifying condition - This will be reviewed by a physician for qualification.

State Issued ID

Front Facing Photo (A selfie showing your shoulders and above)

After you click submit, your card will be charged for $100. Your receipt will be emailed to the email above and you will be contacted by a Bluebird Wellness Center specialist to complete your registration.

I agree to the Terms & Conditions