Self Pre-Screening

This form can help determine if you qualify for a Utah Medical Card based on a few simple questions. This information is private and not shared. If you need help, call or text (801)851-5554.
Date / Time
Name*

First NameLast Name
How did you hear about us?*
E-mail (use the same one you will use to register with the state).*
Phone Number

Area CodePhone Number
Age*
Date of Birth*

MonthDayYear
State of Residence (We are only able to accept Utah residents as patients) *
Zip Code*
Do you have a valid Utah Driver's License or ID?*
My main complaint is:*
Are you actively seeing a provider for your PTSD diagnosis?*
My OTHER complaint is:*
Sometimes {myOther} is caused by or can lead to other symptoms such as frequent headaches, nausea, or pain, which are qualifying conditions for Medical Cannabis Cards in Utah. If this is true for you, please select one that applies.
Other Complaint
The options above are currently the only conditions listed as qualifying conditions for a Medical Card in Utah. If you feel you should be considered and you have a different condition, list it here.
How long has this bothered you?*
Have you seen a medical provider for this? Or are you currently in treatment?
List your medical provider and/or therapist here if you have one.
Do you have medical records?
Do you take medications, including over the counter?*
Which of the following common medications do you take (if any)? You may select more than one.
Select what you have tried for relief. You may select more than one. *
Tell us a little about it.
KindlyMD provides more than just Med Cards. Would you be interested in us managing more of your medications, labs, and care?*

YesMaybeNo, thanks
Please select your health insurance provider*
Responsible Party Signature*

I certify that this information is true and correct. I accept communications with Utah THC for the purpose of medical evaluation and cannabis education.
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