Dears Pharmacy – Eligibility Assessment

We see patients with a wide variety of conditions and guide them through the entire process, making it as safe and straightforward as possible to access the treatment you need. At the start of this process, patients may have questions about potential treatment with medical cannabis and our clinical team are here to help answer these.

By completing this short form, one of our team will be in touch to discuss your condition and current treatment. If appropriate, they will also explain the next steps to booking an appointment.

Assisted Referral Form - Dears
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Referral Details

Patient Consent

Consent *

After completing this short form, a member of our team will be in touch to discuss the next steps to booking an appointment. Please now fill in the patients details below.

Carer / Guardian

Please give Carer/Guardian contact details below.

Patient Information

Confirmation *