Please fill out to apply to Fresh Collective
The information you enter below is not stored on our server our privacy policy ensures that your personal information will only be used to fill your order. Please enter all pertinent information as we cannot verify a doctors recommendation without it and cannot deliver to incomplete addresses. We strive to give our members extraordinary personal attention.  So take a few moments and tell us about you with our convenient form below. If you are unsure of the information needed, please enter what information you have and we will contact you.

First Name: *
Last Name: *
Address Street 1: *
Address Street 2:
City: *
Zip Code: * (5 digits)
Daytime Phone: *
Evening Phone:
Email: *
Doctors Name: *
Doctors Phone: *
Doctors Website Verification URL : *
Patient ID Number: *
Rec Issue date: *
Rec Expiration date: *
Comments:




1523 North La Brea Avenue - Los Angeles, California 90028
323.603.7531
info@freshcollective.org