Medical Cannabis Application

Please complete the form to find out if you are eligible.

Your Details

First Name

Last Name

Date of Birth

Email Address

Phone

Address

Please list the medical condition(s) you are applying for treatment for

Previous assessments and treatments (please include over the counter medicines)

Are you an existing medical cannabis patient?

Yes

Have you previously been rejected for medical cannabis?

Yes

Do you have any history of psychosis or schizophrenia?

Yes

If so please provide details

Do you have any history of contact with any of the following services?

The Community Drug and Alcohol

Team (CDAT)

Child and Adolescent Mental Health Services (CAMHS)

Counselling Services

Drug Concern/In-Dependance

Pain Clinic

Adult Mental Health Services

Psychological Therapies

The Medical Specialist Group

Other

If other please provide here

If you have it, please upload your patient notes here:

Upload File

Upload supported file (Max 15MB)

Your GP's Name

GP Surgery

Do you consent to us contacting your GP and for them to share your records wth us

Your GP's Phone number

If "Other" please provide your GP surgery

I confirm that I have read, fully understood and accept the terms of use: View terms of use

I consent to Pura Health corresponding with my my GP, including sharing this application form and to my GP providing Pura Health with my medical records, or a summary thereof.

Thanks for submitting!

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Medical Cannabis Application

Your Details

FREQUENTLY ASKED QUESTIONS

FREQUENTLY ASKED
QUESTIONS