Jiffy Doctor - FINAL AND CORRECT Patient Registration

Name*

First NameLast Name

Email

example@example.com

What is the OMMA Password you used to create your account?

Address*

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Phone Number*

Please enter a valid phone number.

Date

If Full Service, please upload your Driver's License here:

For Our Full Service Patients ONLY.

Are you a 100% Disabled Veteran?*

YesNo

If you answered yes to being a disabled veteran, please upload proof of your disability.

If Full Service, please upload your insurance card here:

Where do you want your medical card mailed?

Please upload the front and back copy of your payment method for Jiffy Doctor to pay your State Fees unless you are going to pay it yourself.

Signature

My Products

Returning Loyal Jiffy Patient Special Product Image

Returning Loyal Jiffy Patient SpecialThank you for your loyalty! Full Service recommendation. We upload your information to the State.

$50.00

New PatientFull Service recommendation. We upload your information to the State.

$100.00

Renewal PatientFor Patients who need a renewal. We upload your information to the State.

$75.00

DISPENSARY KIOSK-Full Service Product Image

DISPENSARY KIOSK-Full ServiceYou must be at a dispensary kiosk or patient drive for this special pricing. Dispensary will verify.

$25.00

VETERAN-Full ServiceThank you for your dedicated service! Full Service recommendation. We upload your information to the State.

$50.00

SENIOR-Full Service 65 or Older. Full Service recommendation. We upload your information to the State.

$50.00

Pediatric-Doctor OneFull Service recommendation. We upload your information to the State.

$35.00

Pediatric-Doctor TwoFull Service recommendation. We upload your information to the State.

$35.00

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

OKLAHOMA PATIENTS

Your OMMA State Fee that we will pay for you to get your Medical Card. Please read and then upload your payment method, front and back, on the next section.

Jiffy Doctor - Patient Registration