Health Declaration

medical marijuana.jpg

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. 

cut out
cut out

Thank You!

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