Medical Cannabis Sign Up

Email*

Tell us about your condition*

Have you previously tried at least two other licensed medications, treatments or therapies? *

Yes No

Have you, or an immediate family member, been diagnosed with psychosis or schizophrenia? *

Yes No

Are you transitioning from another medical cannabis clinic? *

Yes No

Are you currently a student, claiming benefits, or a veteran? *

Yes No

GP * Private GP?

Your information and consent *

IYOS Pharmacy coordinates your referral to a partner clinic for assessment. Completing this form does not guarantee a prescription.

NHS number (optional)

(Find this on NHS letters, prescriptions, or the NHS app)

Medical records and referral *

I give permission for authorised healthcare professionals at IYOS Pharmacy and my partner clinic to view my Summary Care Record where necessary for my assessment or care.

I authorise IYOS Pharmacy and my partner clinic to obtain relevant medical records and clinical letters from my healthcare providers.

I agree to IYOS Pharmacy and my partner clinic sharing my contact details, eligibility answers and relevant medical information to arrange my referral and coordinate my care.

We will identify your clinic before sharing information. You can withdraw permission by contacting us, but this may affect your assessment or care. Some records must still be retained. See our Privacy Notice.

Signature * (Sign below to confirm consent for accessing NHS records)

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Contact

IYOS Pharmacy and your partner clinic may contact you by email, phone or SMS about your enquiry and care, excluding marketing. Tell us if a contact method is unsuitable.

Your declarations *

My answers are accurate and complete to the best of my knowledge.

I agree to the Terms and Conditions.

Privacy Notice • Terms and Conditions

Your information and consent *

Medical records and referral *

Contact

Your declarations *

Application Submitted!