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Become a member in just three simple steps.

1. Please complete all required fields in the application form below.

2. Upload images of your valid California ID and a picture of you holding the ID.

3. Read and consent to the Lifted Health & Wellness Membership Agreement and Member Terms & Conditions, and then click submit.

In order to receive deliveries from the Lifted Health & Wellness Collective, you must first become an approved patient/member. Simply submit the required documents and we’ll contact you when we’ve approved your membership. Documents can be submitted via the form below or emailed directly to us at staff@lifted420.org. If you have any questions or difficulties, feel free to contact us any time during normal business hours. Thanks for your interest in joining Lifted Health & Wellness.

Your Name (required)

Your Email (required)

Your Phone Number (required)

Physical Address
Street Number and Name, Apartment/Unit Number

Zip Code

Special Instructions
(Call Box Code, Parking Info, Other Instructions)

How Did You Hear About Us? (required)

If a friend/doctor/clinic referred you, what is their name?

Current doctor’s recommendation (max file size 1 MB)

Valid California photo ID (max file size 1 MB)

I have read and consent to the Lifted Membership Agreement and the Lifted Terms and Conditions by checking this box. (required)