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.

Assisted Referral Form - Partner

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Referral Details

Please confirm where you are referring this patient from by entering the PHAR code *

Patient Consent

Consent *

I confirm that I have consent from the patient to complete this form on their behalf.

PLEASE NOTE: 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

Does this patient have a parent or guardian? *

Please give Carer/Guardian contact details below.

Title *

First Name *

Last Name *

Email *

Phone *

Patient Information

Title

First Name *

Surname *

Date of Birth *

Phone Number *

Email Address *

Address Line 1 *

Address Line 2

City *

Country *

Postcode *

Confirmation *

The patient is aware of the costs associated with the appointment and medicines. Pricing details can be found here.

Overall Rating for this Location	Good
Are Services Well-led?	Outstanding

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