Eligibility Checker
Please note that your information is saved on our server as you enter it.
01
Treatment Information
02
Your Information
03
Summary Care
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
*
Select an option
Attention Deficit Hyperactivity Disorder
AFID
Arthritis
Anxiety
Autism Spectrum Disorder
Back and/or Neck Pain
Cancer-Related Pain
Chemotherapy Induced Nausea and Vomiting
Chronic Nausea
Chronic Pain
Colitis
Crohn's Disease
Depression
Eating Disorders
Epilepsy
Fibromyalgia
Glaucoma
Headaches
Insomnia
Irritable Bowel Syndrome
Migraines
Mood Disorders
Movement Disorder
Multiple Sclerosis
Muscle Spasms
Neuropathic Pain
Obsessive Compulsive Disorder
Parkinson’s Disease
Post Traumatic Stress Disorder
Scoliosis
Spinal Cord Injury/Disease
Stress
Tourette’s Syndrome
Tremors
Other (Not listed)
Have you previously tried at least two other licensed medications, treatments or therapies?
*
Yes
No
Have you ever been diagnosed with Schizophrenia or psychosis?
*
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
*
Select an option
Male
Female
Non-Binary
Other
Not Specified
Address Details
Postcode
*
Check Address
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
Create option
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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