General Psychiatry Application Form

Medical Cannabis Initial Application Form

NOTE: This form is Confidential

First name

Last name

Email

Date of birth

Day

Month

Year

Your GP name, address and Postcode

Which psychiatric condition would you like to consider medical cannabis for?

Medical cannabis can be prescribed for any of these five psychiatric conditions. The diagnosis must be stated on the Summary Care Record, with evidence that at least two previous medical treatments have been tried for the condition previously.

Please tick if you have a history of any of the following conditions:

Unfortunately a history of any of these conditions would make you exempt from receiving medical cannabis.

I consent for my GP to be contacted to provide a copy of my Summary Care Record (SCR) ahead of the Initial Medical Assessment.

Yes

No

Please provide a copy of your Summary Care Record, wehich can be obtained from your GP, aghead of the Initial Medical Assessment. Thus can be emailed to me at: drbensessa@gmail.com

I confirm that I the information I have provided is accurate.