Check if you are eligible for medical cannabis
By completing this questionnaire, you can check if you are eligible to apply for medical cannabis as an alternative to pharmaceutical medication. Once the answers are submitted, you will be contacted by phone and/or email within 3 working days with further instructions on setting up an appointment for an initial consultation.
Sign in to Google to save your progress. Learn more
Email address *
Name and surname *
ID card number *
Mobile number *
Age *
Reason(s) for requesting medical cannabis *
Are you under the care of a doctor (GP / consultant)? *
Did you discuss medical cannabis with your personal doctor? *
Do you have diagnostic evidence of your condition? *
Do you have a history of heart disease or respiratory disease? *
Are you under the care of a psychiatrist? *
Do you have a personal or family history of schizophrenia or bipolar disorder? *
List the names of the medications you are using or have used in  the past to relieve your symptoms *
Were the medications effective to relieve symptoms? *
What side effects did the medication give you? *
Did you ever have any trouble with the police? Do you have pending court cases? Are you on probation ? *
Did you ever attend Detox Centre (for substance misuse)  in the past? *
What is your current occupation? *
Have you ever used cannabis or CBD before? *
Who referred you to The Pain Clinic?
Where would you like your appointment?
Clear selection
Kindly pay the processing fee by clicking here and provide the order number below *
By selecting "Agree" below, you declare that you take full responsibility of your use of this medicine. If you smoke, sell, share, drive under the influence or abuse the medicine in any way, you could be liable to criminal charges. *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy