"; } if(!$_POST['lastName']) { $thankYou = false; $err.= "Last name is required.
"; } if(!$_POST['email']) { $thankYou = false; $err.= "Email address is required.
"; } if(!$_POST['phone']) { $thankYou = false; $err.= "Phone number is required.
"; } if(!$_POST['bday']) { $thankYou = false; $err.= "Birthday is required.
"; } if(! check_valid_email($_POST['email'])) { $thankYou = false; $err.= " A valid email address is required.
"; } if( strlen($_POST['phone']) < 10) { $thankYou = false; $err.= "Please enter a valid 10 digit phone number
"; } /* if(!$_POST['address']) { $thankYou = false; $err.= "Address is required.
"; } if(!$_POST['city']) { $thankYou = false; $err.= "City is required.
"; } if(!$_POST['state']) { $thankYou = false; $err.= "State is required.
"; } if(!$_POST['zipcode']) { $thankYou = false; $err.= "Zipcode is required.
"; } */ if($_POST['q1']=='0' || $_POST['q4']=='0' || $_POST['q5']=='0' || $_POST['q6']=='0' || $_POST['q7']=='0' ) { $thankYou = false; $err.= "You must answer all questions yes or no.
"; } if(!$_POST['nearestZipcode']) { $thankYou = false; $err.= "Nearest Zipcode is required.
"; } foreach($_POST as $k=>$v) { if( ereg('cond_',$k) ) { $_POST['conditions'].= trim(str_replace('cond_','',$k )).', '; } if( ereg('appointments_',$k) ) { $_POST['appointments'].= trim(str_replace('appointments_','',$k )).', '; } } $_POST['conditions'] = substr($_POST['conditions'],0,-2); $_POST['appointments'] = substr($_POST['appointments'],0,-2); if(!$_POST['conditions']) { $thankYou = false; $err.= "Atleast 1 medical condition is required.
"; } if(!$_POST['appointments']) { //$thankYou = false; //$err.= "Choosing appointment times is required.
"; } if($thankYou) { $_POST = array_map('mysql_real_escape_string',$_POST); if($_POST['tmpID']) { mysql_query("UPDATE `".DB_TABLE."` SET `firstName`='".$_POST['firstName']."', `lastName`='".$_POST['lastName']."', `phone`='".$_POST['phone']."', `email`='".$_POST['email']."', `address`='".$_POST['address']."', `city`='".$_POST['city']."', `state`='".$_POST['state']."', `zipcode`='".$_POST['zipcode']."', `q1`='".$_POST['q1']."', `q2`='".$_POST['q2']."', `q4`='".$_POST['q4']."', `q5`='".$_POST['q5']."', `q6`='".$_POST['q6']."', `q7`='".$_POST['q7']."', `q8`='".$_POST['q8']."', `q9`='".$_POST['q9']."', `list1`='".$_POST['list1']."', `list2`='".$_POST['list2']."', `list3`='".$_POST['list3']."', `list4`='".$_POST['list4']."', `list5`='".$_POST['list5']."', `bday`='".$_POST['bday']."', `comments`='".$_POST['comments']."', `nearestZipcode`='".$_POST['nearestZipcode']."', `conditions`='".$_POST['conditions']."', `appointments`='".$_POST['appointments']."', `renew`='1', `time`='".time()."' WHERE `id`='".$_POST['tmpID']."'"); } else { mysql_query("INSERT INTO `".DB_TABLE."` SET `firstName`='".$_POST['firstName']."', `lastName`='".$_POST['lastName']."', `phone`='".$_POST['phone']."', `email`='".$_POST['email']."', `address`='".$_POST['address']."', `city`='".$_POST['city']."', `state`='".$_POST['state']."', `zipcode`='".$_POST['zipcode']."', `track`='".mysql_real_escape_string($track)."', `q1`='".$_POST['q1']."', `q2`='".$_POST['q2']."', `q4`='".$_POST['q4']."', `q5`='".$_POST['q5']."', `q6`='".$_POST['q6']."', `q7`='".$_POST['q7']."', `q8`='".$_POST['q8']."', `q9`='".$_POST['q9']."', `list1`='".$_POST['list1']."', `list2`='".$_POST['list2']."', `list3`='".$_POST['list3']."', `list4`='".$_POST['list4']."', `list5`='".$_POST['list5']."', `bday`='".$_POST['bday']."', `comments`='".$_POST['comments']."', `nearestZipcode`='".$_POST['nearestZipcode']."', `conditions`='".$_POST['conditions']."', `appointments`='".$_POST['appointments']."', `renew`='1', `time`='".time()."'"); } header("Location: /thankYou.php"); } } if($_POST && $_REQUEST['type']=='short') { $short = 'Please fill out the remainder of the form below so we can qualify your application.'; if($_POST['q1']=='n' || $_POST['q3']=='n' || $_POST['q4']=='n' ) { header("Location: /sorry.php"); die(); } if(!$_POST['firstName']) { $thankYou = false; $err.= "First name is required.
"; } if(!$_POST['lastName']) { $thankYou = false; $err.= "Last name is required.
"; } if(!$_POST['email']) { $thankYou = false; $err.= "Email address is required.
"; } if(!$_POST['phone']) { $thankYou = false; $err.= "Phone number is required.
"; } if(! check_valid_email($_POST['email'])) { $thankYou = false; $err.= " A valid email address is required.
"; } if( strlen($_POST['phone']) < 10) { $thankYou = false; $err.= "Please enter a valid 10 digit phone number
"; } if($_POST['q1']=='n' || $_POST['q3']=='n' || $_POST['q1']=='n' ) { header("Location: /sorry.php"); die(); $err = 'err'; } if($_POST['q1']=='0' || $_POST['q4']=='0' ) { $thankYou = false; $err.= "You must answer all questions yes or no.
"; } if(!$_POST['nearestZipcode']) { $thankYou = false; $err.= "Nearest Zipcode is required.
"; } foreach($_POST as $k=>$v) { if( ereg('cond_',$k) ) { $_POST['conditions'].= trim(str_replace('cond_','',$k )).', '; } if( ereg('appointments_',$k) ) { $_POST['appointments'].= trim(str_replace('appointments_','',$k )).', '; } } $_POST['conditions'] = substr($_POST['conditions'],0,-2); $_POST['appointments'] = substr($_POST['appointments'],0,-2); if(!$_POST['conditions']) { $thankYou = false; $err.= "Atleast 1 medical condition is required.
"; } if(!$err) { $_POST = array_map('mysql_real_escape_string',$_POST); mysql_query("INSERT INTO `".DB_TABLE."` SET `firstName`='".$_POST['firstName']."', `lastName`='".$_POST['lastName']."', `phone`='".$_POST['phone']."', `email`='".$_POST['email']."', `address`='".$_POST['address']."', `city`='".$_POST['city']."', `state`='".$_POST['state']."', `zipcode`='".$_POST['zipcode']."', `track`='".mysql_real_escape_string($track)."', `q1`='".$_POST['q1']."', `q2`='".$_POST['q2']."', `q4`='".$_POST['q4']."', `q5`='".$_POST['q5']."', `q6`='".$_POST['q6']."', `q7`='".$_POST['q7']."', `q8`='".$_POST['q8']."', `q9`='".$_POST['q9']."', `list1`='".$_POST['list1']."', `list2`='".$_POST['list2']."', `list3`='".$_POST['list3']."', `list4`='".$_POST['list4']."', `list5`='".$_POST['list5']."', `bday`='".$_POST['bday']."', `comments`='".$_POST['comments']."', `nearestZipcode`='".$_POST['nearestZipcode']."', `conditions`='".$_POST['conditions']."', `appointments`='".$_POST['appointments']."', `renew`='1', `time`='".time()."'"); $tmpID = mysql_insert_id(); $short = 'Thank you, we have received your basic application! To better qualify your status please fill out the remainder of the application below.'; } } $title = 'OMMP Card Renewals | Renew Your OMMP Card | OMMP Doctors'; $desc = 'Complete the online renewal application and our Doctor will renew your OMMP card. Apply to renew your OMMP Cannabis Card in Oregon.'; $keywords = 'Oregon Medical Marijuana Cards Renewal, medical marijuana renewal doctors oregon, medical marijuana renewal clinic oregon, '; include '_header.php'; ?>

Oregon Medical Marijuana Card Renewal Application


1Apply Below

Complete the application below, you will then be directed to a medical records release form, this important step will allow us to start working on your application.

2Physician Review

Once your deposit is made and your appointment set, your records will go into an advanced review with our physician to determine your eligibility.

3Renew Your Card

Attend your scheduled appointment for the completion of you state application, then simply mail the application to the state and your card will be mailed to you.

We have received your information and will contact you shortly to discuss your application and scheduling. Thank you!
'.$err.'
'; } ?>
Step 1 - Contact Information
First Name:
Middle Initial:
Last Name:
Phone:
Birthday: (MM/DD/YYYY)
Email: (Updates will be sent here)
Confirm Email:
Step 2 - Basic Qualifications
Are you 18 or older?
If not 18, you must have a parents signiture on the final application. If you have your parents permission, click "yes" to this questions to submit.
Do you have a valid government issued ID?
Sorry you must have a valid ID
Step 3 - Qualifying Medical Conditions
Only choose conditions that have been FORMALLY diagnosed (based on lab, x-ray, MRI results, ETC.) by your MD or DO with corresponding medical records. NOTE: If you are currently pregnant or breastfeeding, please wait to complete an application until you are not.

Severe Pain  
Nausea  
Muscle spasms  


Click here for common condtions which may qualify under "Severe Pain", "Severe Nausea", and/or Muscle Spasms

PTSD  
Multi. Sclerosis  
Cachexia  
Cancer  
Glaucoma  
HIV+/AIDS  
Seizures  
Epilepsy  
Alzheimer's  


Please list your EXACT diagnosis and current treatments:
Step 4 - Medical Records
Have you visited an MD to discuss this specific condition?
Do you have copies of these medical records in your possession?
Have you been prescribed any medications for your condition?
On your worst day, what is your symptom severity level? 1 = Mild & 10 = Severe:
Step 5 - Doctor Recommendation
Schedule an appointment to get your doctors recommendation at our marijuana clinic.
Which clinic location is most convenient for you?
Would you like to receive more information regarding any of the following resources?
Cannabis Dispensaries  
Cannabis Delivery Services  
Finding a grower  
Becoming a grower for other patients 
Volunteering at the OMMC Clinic 



By submitting this application, you confirm that all the information you provided is true and accurate. We look forward to working with you and will contact you shortly!