Eligibility Assessment » Wellford Medical Clinics

Finish your Eligibility Check

Please complete the form below to complete your eligibility check. Once you’re done, we will email you a copy of your information, so you can keep it as a record of your progress.

Triage 2

Which best describes you?

Carer / Guardian Details

Carer/Guardian First Name

Carer/Guardian Last Name

Carer/Guardian Email

Carer/Guardian Phone

Patient Details

Title

Patient First Name

Patient Last Name

Patient Email

Patient Phone

Address 1

Address 2

Town / City

Postcode

Date of Birth

Age

You must be over 18 to access medical cannabis in the UK.

Discount Code

Health & Medical History

Condition

Please select the primary condition you would like us to speak to us about.

GP Name

GP Email

GP Address

You can look up your GP address here.

Please give details of medical any diagnoses you have obtained

Please provide details of treatment you are currently receiving e.g. talking therapy

Please provide details of any current or past medication

Please provide full details of any nutritional supplements you currently take

Declaration

I am aware that I will be required to pay for my Doctor consultations

I am aware that I will be required to pay for my ongoing medical cannabis treatment

Your Summary of Care

Your summary care record is available through your GP and we will require this prior to your appointment.
To speed up the time it takes to access your medical records via your GP, you can give us permission to contact them and request your Summary of Care directly. Check one of the boxes below.

Summary of Care Permission

Yes, I consent that Wellford Medical Clinics may write to my GP and request my Summary of Care record.

No, I will ask my GP to send my Summary of Care to [email protected].

Signature

Clear

Please provide your signature to confirm.

Your Data

I give Wellford Medical Clinics permission to use the information I share in this form to communicate with me, and to care for my wellbeing. I am aware that I can opt-out at any time via email to [email protected] and request my data be removed.

If you are human, leave this field blank.

Please note, you can withdraw your contact consent at any time by contacting [email protected]. Any information you share with us in this form will never be shared with a third party.