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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 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)