1a) Application

Start your journey today! Apply for your medical card in three easy steps.

Only $99 due at time of service. Cash, Card, or HSA. There is NO CHARGE if our QMP determines we can't get you qualified. $6 Additional charge if a card is used upon check-in. WE PRICE MATCH ANY UTAH COMPETITOR! just show us the clinic, and we'll match it.
Step 1

Complete Pre-Screening Form

Step 2

Schedule your Appointment

Step 3

Alpply for your Utah Medical Card with the State
Let's get started!

It is important to us that this is a stress-free, easy experience for you, so let us walk you through it step by step.
RESTRICTIONS- medical card may not be issued to Federal Employees or CDL drivers. I understand that CCW (Concealed Firearm Permit) may be at risk if you get a medical card. We advise you to consult a Utah attorney first.
Step 1 - Pre-Screening

Please give as much detail as you can. Medical records are not required, but they can be helpful if you have easy access to them. Most importantly, just tell us your story and how your daily life has been affected by your condition(s).
Name*

First NameLast Name
Mobile Phone*
Email*
example@example.com
Last 4 of SSN*
Birthdate*

MonthDayYear
Date
How would you describe your gender?*
What is your condition?*
These are the only APPROVED Qualifying Conditions for a Med Card in Utah.
Please bring in any relevant documentation to the condition you have selected.
This condition REQUIRES documentation of your diagnosis, Please bring it with you.
How long have you had this condition?*
Have you seen a doctor for your condition?*
Do you have Medical Records you can upload now?
Records are not needed but could be helpful to get approval
Page 1*

Cancelof
Page 2

Cancelof
Page 3

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What treatments have you tried for relief?*
Do you take any medications?*
Please list all medications you are currently taking*
Please share with us why you believe that being a legal med patient would help your condition?*
This is 100% private, we don't report this to anyone. If you have had positive experience with treatment, our QMP would like to know (you can wait and tell your QMP in person if you prefer).
City of Residence*
How did you hear about Empathetix?*
City of Res (old)
Coupon Code:
Discount Price
What is the name of the person who referred you?
Please enter the proper email address of who referred you so that they can receive their end of the discount.
example@example.com
You have entered our "force" coupon code! The initial medical card price will be discounted to $99! May the force be with you!
The Coupon Code you have entered is expired/inactive or incorrect. We apologize for the inconvenience. To continue on with your booking please clear out any code you have entered.
You have entered our empbar Coupon Code! Initial medical card price will be discounted to $99.

Mobile Event-Brickyard Bar Location only
You've entered U92rocks for 10% off your pre-screen appointment!
You have entered our Feelgood1 Coupon Code! You will receive $50 off of your Pre-Screen appointment. Please be sure to schedule with us on the following page.
You have entered our Feelgood2 Coupon Code! You will receive $50 off of your Pre-Screen appointment. Please be sure to schedule with us on the following page.
You have entered our Feelgood3 Coupon Code! You will receive $50 off of your Pre-Screen appointment. Please be sure to schedule with us on the following page.
You have entered our Feelgood4 Coupon Code! You will receive $50 off of your Pre-Screen appointment. Please be sure to schedule with us on the following page.
You have entered our cannabis code for $40 off your appointment! Please be sure to book your appointment on the following page.
You have entered the code "feelgood" for $21 off your appointment! Please be sure to book your appointment on the following page.
You have entered the Referral Coupon Code! Please check that your referrer's email is entered properly so that we can ensure this discount is applied to them.
Opt In
If you take any prescription medications fill out the information below and let our pharmacy is able to save you money on your med card and/or your prescriptions
Do you have Prescription Insurance
BIN*
Prescription Insurance*
Member ID*
Home Address*
PCN
If Applicable
RX Group
If Applicable
Empathetix is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:
You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.
By clicking submit below, you consent to allow Empathetix to store and process the personal information submitted above to provide you the content requested.
Signature*

Clear
Step 2 - Schedule Appointment

There is no exam, you will simply have a conversation with a compassionate Qualified Medical Practitioner (QMP).
AccountID
Appointment Type
Location
Telemed
Should be Empty:

Start your journey today! Apply for your medical card in three easy steps.

Let's get started!

Step 1 - Pre-Screening

Step 2 - Schedule Appointment