Wize Choice Med

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Wize Choice Patient PortalBook your Virtual Oklahoma Medical Card appointment now in minutes..
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Is Patient 18 Years of Age?* This field is required.Patients must be at least 18 years old by law. Those under 18 must have a parent or legal guardian assigned and processed as a caretaker.
Please Select
Please Select
Yes
No
Please select Yes or No for Over 18 Years of Age
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DOBPlease enter the correct date of birth. (On mobile devices, tap the year and scroll to select the correct date.) Format: MM-DD-YYYY
Date of birth
Month
Day
Year
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Are you applying for A 2 Year License & or Renewal?Please select the best answer..
YESNO
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Are you applying for A 60 Day Short Term License?Please select the best answer..
YESNO
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Full NamePlease enter your full name. Make sure the information matches exactly with the documents you will provide.
First Name
Last Name
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IMPORTANT: Please provide a unique email address for each patient. Dispensaries or assistants must use the patient’s email address.* This field is required.Valid UNIQUE Email Required for each Successful submission
example@example.com
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Do You Need OMMA Upload Assistance |+ $20 Fee* This field is required.By selecting YES and submitting this form, you consent to the use of all sensitive information, documents, and media provided to Wize Choice Med for the sole purpose of completing the patient upload checklist and fulfilling OMMA patient application requirements, including verification of personal information, ID, and proof of residency within your patient account.
Please Select
Please Select
YES
NO
Please Select Yes or Now (Omma Upload Assistance +$20)
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Do You Plan to Use A Care Giver?Please let us know if you plan to request caregiver approval from the doctor.
YESNO
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Are you Enrolled in Medicaid, Medicare, Or SoonerCare?A file upload of supporting documentation is required to Complete Processing If not Provided this will result in A Delay.
YESNO
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Email Provided is the Same As Current OMMA Or Can be used as such..I understand that when Providing my Email it either needs to be the same email as the Current OMMA Account Or the Email that you would like to use for your OMMA State Patient Account ONLY if State Processing & Upload Is Needed...
YESNO
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Patient Residency & Address Info. Please use the same address that will be on the document used to Prove Residency. (PO BOXES NOT ACCEPTABLE except in Mail To Address in the Next Section) IF YOU HAVE MOVED
Street Address
Apt/suite
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Is the Address you want your Med card Mailed?
YESNO
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Mail to AddressAddress that the Med card would need to be sent to in the event the proof of Residency address is not where you want the card sent.
Mailing Street Address
Apt / Suite
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Patient PhotoMust Be on sold white background no smiling, NO FILTERS, NO GLASSES, Must show tops of shoulders (Nothing Obstructing Face)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Sooner Care or Medicaid or 100% Disabled Military Documents for Reduced Fees.Please Provide Front Side Pic of Sooner or Medicaid or Military Document
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Phone Number* This field is required.Please provide your phone number as an agent will be calling to confirm your submission & help you get your appointment scheduled with the Doctor & may have questions.
Please enter a valid phone number.
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Please Share A Little info About why your Applying for your MMJ Rec?Info to be Shared with Doctor- In the State of Oklahoma there are no qualifying conditions required for approval. Doctors approval is however dependent on doctors discretion & medical recommendation.
Huge
Large
Normal
Small
Ok
Ok
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Authorization of Privacy Consent & Release (Do You Grant Permission)Authorization of Privacy Release. I authorize wizechoicemed.com, an online doctor appointment booking agent and patient services liaison, to collect and use my personal information collected to schedule a virtual appointment and assess my eligibility for an Oklahoma medical card. I further authorize the use and sharing of my information with: The doctor(s) for appointment booking and eligibility assessment via virtual appointment. The Oklahoma Medical Marijuana Authority (OMMA) for patient account creation and processing my Oklahoma Medical Marijuana Card application if applicable. The information shared includes what is necessary to schedule appointments, verify identity, assess eligibility, provide medical recommendations, and complete the OMMA medical marijuana application process. This authorization is effective for 60 days from the date signed below unless I revoke it earlier. I understand that: Signing this authorization is required for wizechoicemed.com to provide these services. Without my signature, these services cannot be provided. I may revoke this authorization at any time by notifying wizechoicemed.com in writing or verbally, but this will not affect information already shared. My information will remain stored with wizechoicemed.com unless I withdraw permission. Once shared with OMMA, my information will be subject to OMMA’s privacy policies and disclosures. By selecting YES below, I confirm I understand and agree to this release.
YESNO
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Authorization of Privacy Consent & Release* This field is required.Signature required
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Doctors Appointments* This field is required.Please select an available Date & Time
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Please Screen Shot Or Save your Appointment Time. Please SCREEN SHOT or snap A Photo of your appointment time. Check your Email for VIRTUAL MEETING instructions after application submission & expect A phone call from A Wize Choice Patient Expert.
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Invoice ID
24
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ORDER SUMMARY
Total costUSD
$49 - Doctors Recommendation Only (You must submit within 30 days) + to Add Service
$49 Doctors Consultation & Appointment. NO State UPLOAD SERVICE. You will still need to complete state application & pay all applicable state fees..
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$69 - New Patient Or Renewal Application + Uploads (Does NOT Include State Fee)
Full Service New Patient Application Or Renewal + Uploads includes $49 Doctors Consultation & virtual Appointment | $20 Upload Fee | PATIENT PAYS 104.30 STATE FEE
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$69 - Discounted | Sooner care | Medicare | 100% disabled military ONLY New Patient Or Renewal Application + Uploads (Does NOT Include State Fee)
Soonercare , Medicare & 100% Disabled Military Full Service New Patient Application Or Renewal, $49 Doctors Consultation & Appointment. $20 Upload Fee | PATIENT PAYS $22.50 STATE FEE
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$50 - Out of State Patient Or Renewal Application (Does NOT Include State Fee)
$50 Upload Fee | must provide you current valid medical marijuana license from your state in which you reside. PATIENT PAYS $104.30 Required State Fee
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