Dazed Vixens - Become a Vixen

If you are a medical user with a valid prescription in the state of California and would like to become one of the Dazed Vixens, fill out this application.

Upload up to 3 photo samples
jpg, png or gif format only.

Your Name
Email Address
Birthdate - You must be at least 18 years old.
Month
Day (DD)
Year (YYYY)

Why you want to be a Vixen:
I agree to the terms and conditions.