The Variety’s Pre-Verification Process @ The Variety Co-op

The Variety’s Pre-Verification Process

Save time and sign up with the pre-verifcation form below!

Remember to bring your Original Physician’s Statement AND valid California I.D. Also, we are only accepting patients from L.A. and Orange county.

Pre-Verification Form

Are you from Orange County or LA County? Thank you.
Orange County LA County

Patient First Name (required)

Patient Last Name (required)

Patient Address (required)

Patient's Email Address

Patient's Phone Number (required)

Patient ID (If Applicable)

Date of Birth (required)

Date of Statement (required)

Doctor's Name (required)

Doctor's Office Name (If Applicable)

Doctor's Website (If Applicable)

Doctor's Phone Number (required)

Doctor's License Number (required)

Patient ID (If Applicable)

Any additional Comments