Eligibility Checker

Email address^*

We will use this email address to send you a copy of your responses and save your form progress to return to later.

Reason for treatment^*

Have you previously tried at least two other licensed medications, treatments or therapies?^*

Yes

No

Have you, or an immediate family member, been diagnosed with psychosis or schizophrenia?^*

Yes

No

Are you transitioning from another medical cannabis clinic?^*

Yes

No

Are you a veteran or currently claiming benefits?^*

Yes

No

By checking this box, I confirm I am aware there is a cost associated with the clinic consultations and medication I may be prescribed

Please click here to learn more about our prices.

First name^*

Last name^*

Date of birth^*

Phone number^*

Gender^*

Address Details

Postcode^*

Address line one^*

Address line two

Address line three

Town / City

Address county

Address country^*

We require your Summary Care Record (Emergency Care Summary in Scotland) to confirm your eligibility. Please confirm your answers below.

General Practitioner

If you can't find your GP, tap or click the + icon to add your GP details.

GP Email

We don't have this surgeries email address on record. If you don’t know or can’t find your GP’s email address and would like MAMEDICA to obtain your medical record, please contact your GP by phone for their email to avoid any delays.

NHS Number

This is the 10-digit number found on any NHS letter or prescription

I give consent for Mamedica to obtain my Summary Care Record and any other clinical letters related to my condition, to process my application.^*

Referrer

Please contact me in relation to my treatment, I understand this maybe via email, phone or SMS.^*

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