MEDICAL CANNABIS- ARE YOU A CANDIDATE?

Medical Cannabis PreScreening

QHW Cannabis RX Guided Therapy NOW available in person/telemed
Quintessence Health and Wellness

Ketamine therapy for pain/PTSD- Talk to your provider in your appt
Name *

First Name Last Name
Date of Birth *

Month Day Year
Email *
example@example.com
Phone Number *
Address *

Street Address

Street Address Line 2

City State

Zip code
Last 4 Digits of Social Security Number *
Gender *

Female Male Other
Occupation
Are you Currently using Cannabis for a medical condition? *

Yes No
If yes, what medical condition do you use Cannabis for?
Utah Medical Cannabis Qualifying Conditions (check allyou feel you qualify for): *

Pain lasting longer than two weeks that is not adequately managed, in the qualified medical provider’s opinion, despite treatment attempts. PTSD (which is treated by a licensed mental health therapist and has been diagnosed either by the VA or through an evaluation by qualified mental health specialist) HIV or AIDS Alzheimer’s Disease Amyotrophic Lateral Sclerosis (ALS) Cancer Cachexia Persistent nausea Crohn's Disease/Ulcerative Colitis Epilepsy / debilitating seizures Multiple sclerosis / persistent and debilitating muscle spasms Autism Terminal illness with less than six months life expectancy A condition resulting in the patient receiving hospice care A rare condition or disease that affects less than 200,000 individuals in the United States and is not adequately managed by a non-opioid or physical intervention I do not see any that apply to me, please help me look for anything else that may qualify me. - You will need to call or text the office to speak to staff for back up options If I don't qualify, I would like more information on the Ketamine Program. It is easier to qualify for Ketamine treatments because it is used off label. Very effective.
List all medications currently taking
Do you drink alcohol

Yes No
Please list all allergies
Do you Smoke Cigarettes:

Yes No Vape
Do you use recreational drugs

Yes No
List all Past Medical and/or mental health History not listed above
Have you had any blood labs done in the last 3 months?

Yes No
Would like to check your hormone levels- it costs $125 or you can use insurance. and you will go over your results with Dr. Adam Larson via telemed. We do offer VIRTUAL comprehensive Hormone Therapy.
Fill out this short eval to get labs ordered with our MA.
Financial Agreement

During the first year having your medical cannabis card, there are fees associated with the process.
- Your initial QMP appt - $225
  - Appointment with the QMP
  - Medical record review
  - EVS Registration
  - 90-day renewal
- If you transfer QMP care - $100
  - Appointment with the QMP
  - Medical record review
  - EVS Registration
  - 90-day renewal
- Your 6 month follow up - $75
  - Telehealth or Phone call with the QMP
  - EVS Renewal
- Your 12/18/24 month follow up - $75 each or $225 for the year
  - Telehealth or Phone call with the QMP
  - EVS Renewal
The state requires these follow up appointments and these are the Quintessence Health and Wellness fees associated with the follow up appointments.
Please check the following: *

I understand it is my responsibility to stay up to date about the Utah polices and laws regarding Cannabis use. Moreover, I understand Quintessence Health and Wellness is not responsible for educating me or my party of the current or upcoming changes of said policies and laws.
All the Information I have provided is true and accurate to the best of my knowledge.
Please check the following: *

I understand it is my sole responsibility to seek or continue receiving treatment for my qualifying condition from my Primary Care Physician or Specialist. I understand that by getting approved for medical cannabis, the clinic QMP is NOT diagnosing or treating my condition. I understand that I need to provide medical records for my condition. I will have my medical records and drivers license with me at my appointment.
Signature *

Clear
Date *

Month Day Year
Date
Which location is best? *

Sandy, Tues or Wed Kaysville Fri afternoon
Should be Empty:

Medical Cannabis PreScreening

Quintessence Health and Wellness