MEDICAL CANNABIS- ARE YOU A CANDIDATE?

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FULL NAME* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date
Month
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Input in exact same format
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Address* This field is required.
Street Address
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Last 4 Digits of Social Security Number* This field is required.
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Gender* This field is required.
Female
Male
Other
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Occupation
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Are you Currently using Cannabis for a medical condition?* This field is required.
Yes
No
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If yes, what medical condition do you use Cannabis for?
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Utah Medical Cannabis Qualifying Conditions (check allyou feel you qualify for):* This field is required.
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.
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List all medications currently taking
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Do you drink alcohol
Yes
No
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Please list all allergies
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Do you Smoke Cigarettes:
Yes
No
Vape
16
Do you use recreational drugs
Yes
No
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List all Past Medical and/or mental health History not listed above
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Have you had any blood labs done in the last 3 months?
Yes
No
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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.
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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.
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Please check the following:* This field is required.
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.
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Please check the following:* This field is required.
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 VALID STATE ID with me at my appointment. A letter from a Dr. or Chiropractor is sufficient.
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CHECK LIST PRIOR TO GETTING CARD* This field is required. SEE INSTRUCTIONAL VIDEO IN EMAILED LINK WITH THESE STEPS
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Date* This field is required.
Date
Month
Day
Year
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All the Information I have provided is true and accurate to the best of my knowledge if this form is signed
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Signature* This field is required.
Clear
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Which location is best?We Recommend Using the SELF SCHEDULER (3rd Option OR submit to redirect to schedule)
Draper
Kaysville, Fri afternoon
OR BOOK HERE TO EXPEDITE- https://book.mypatientnow.com/practice/nVwhh3
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