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Sign Up/New Patient Verification Form

Pre-registration requests are usually processed within 24hrs. Some doctor's offices can take up to one week to verify recommendations letters. Please use this form if you are requesting delivery or if you are planning a visit in the next few days. We will contact you and let you know as soon as your pre-registration is complete. Please make sure to bring your ID and recommendation upon your first visit, or have it ready for your first delivery.

We accept CA ID’s, Drivers licenses and passports.
US Bloom has my permission to place calls to me at the number I provide in this Patient Verification Form, with information about US Bloom products or services in which I may be interested. I understand that as a result of giving this permission, I may be contacted by someone calling on behalf of US Bloom (even if my telephone number is listed on the federal "do not call" registry).
Would you like to receive communications from US Bloom about specials, promotions, newsletters, action alerts, and more?

Doctor / Clinic Information

(For verification purposes, the ZIP code on file with your doctor/clinic for your recommendation)