Kentucky Green Life

Complete Form to Contact Us

First Name & Last Name:

Email *

Phone *

Address:

My qualifying condition for Medical Cannabis is cancer.

My qualifying condition for Medical Cannabis is chronic and/or severe pain.

My qualifying condition for Medical Cannabis is epilepsy or another seizure disorder.

My qualifying condition for Medical Cannabis is multiple sclerosis, muscle spasms, or spasticity.

My qualifying condition for Medical Cannabis is chronic nausea or cyclical vomiting syndrome.

My qualifying condition for Medical Cannabis is post-traumatic stress disorder.

If I do not receive an immediate confirmation email, I will remember to check my spam folder.

I understand also that I may not apply for a certification if I am not a Kentucky Resident, ever convicted of a felony, active pregnancy, or a minor ( under 18 years of age).

I understand that I will be contacted within 72 hours time to book an appointment or advise we cannot see you.

FINAL STEP YOU MUST COMPLETE IN ORDER TO BE SCHEDULED ALONG WITH CONTACTING US

Submit Your Medical Documentation

Once you have submitted your request above please also send us your SSN and a copy of your Driver's License or ID card along with your medical records to housecalls@echp2u.com or by faxing them to 888-232-1268.

Phone Number

502-546-6082

Email Address

Housecalls@echp2u.com

Fax

888-232-1268