510.406.0444    |      info@thestickyrose.com    |    Hours: Mon–Fri: 9 – 5 pm / Sat: 9 – 4 / Sun: Closed

New Patient Verification

We know how important your time is, which is why we make it so simple to register with our dispensary. Just fill out our 3-minute verification form below and click submit. It’s that easy. Your information will be immediately sent to our office where we will manually verify your medical recommendation, usually within five minutes.

Your Name

Your Email

Your Phone

Your Birthdate

Your Street Address

Your City

Doctor's Name

Doctor's Clinic Name

Verification Website

Verification Phone Number

Recommendation Date

Recommendation Expiration Date

Recommendation #

How did you hear about us? (choose one)

ATTN: After submitting this form please email your Recommendation & CA I.D. to info@thestickyrose.com.