Health Declaration

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Qualifying Condition(s)

Allergies to Medication

Check all of the over the counter medications below that you take:

Also, please check all of the medications below that you take:

I certify that the answers I have provided are complete and accurate. 

 

I understand my payment must be made at the time my appointment is scheduled.  I further understand that no refunds will be provided if I cancel within 12 hours of my appointment date, but that prior to that time a full refund will be provided upon my request.  I also understand that the physician does not provide cannabis, the cannabis card (provided by the state of Utah), or accept cash payments; and, that there is no guarantee that the state of Utah will approve my application.  

Next, send us a secure email and let us know your preferred time and date.  We will send you back a link to your personal health record where you can view and change your appointment.

Finally, submit this form, and we will get your certification process started. 

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Thank You!

The next step will be to confirm your appointment and pay for the consultation.