For Patients

Let's start by understanding your eligibility for an assessment by our clinic.
My condition is ...*
- Generalised Anxiety Disorder (GAD)
- Pain, Neuropathic Pain or Chronic Pain
- Post-Traumatic Stress Disorder (PTSD)
- Sleep Disorder
- Attention Deficit Hyperactivity Disorder (ADHD)
Which of these approved (licensed) medications have you been prescribed so far for the condition?*
- SSRI: Fluvoxamine, Fluoxetine, Paroxetine, Escitalopram, Citalopram or Sertraline
- SNRI: Venlafaxine, Duloxetine
- Prebabalin
- Quetiapine
- Benzodiazepine
- Propranolol
- Other
Which of these approved (licensed) medications have you been prescribed so far for the condition?*
- NSAIDs
- NSAIDs with Codeine
- SNRI such as Duloxetine, Tramadol and Venlafaxine
- Amitriptyline
- Gabapentin
- Pregabalin
- Capsaicin cream
- Morphine
- Oxcarbazepine
- Topiramate
- Epidural injections of local anaesthetic or steroid
- Prazosin
- Clonidine
- Propranolol
- Valproic Acid
- Other
Which of these approved (licensed) medications have you been prescribed so far for the condition?*
- Venlafaxine
- SSRI: Sertraline, Fluoxetine, Paroxetine
- Risperidone
- Proporanolol
- Duloxetine
- Quetiapine
- Aripiprazole
- Paliperidone
- Other
Which of these approved (licensed) medications have you been prescribed so far for the condition?*
- Benzodiazepines such as Temazepam, Loprazolam, Lormetazepam, Diazepam and Nitrazepam
- Zaleplon
- Zolpidem
- Zopiclone
- Melatonin
- Other
Which of these approved (licensed) medications have you been prescribed so far for the condition?*
- Atomoxetine
- Guanfacine
- Methylphenidate
- Dexamfetamine
- Lisdexamfetamine
- Other
Other medication*
Number of prescribed medications
To be eligible the patient needs to have been prescribed 2 licenced medications.

Before we finalise your eligibility...
Permission to store*
- I give MyAccess Clinics permission to store and use the information I share in this form to communicate with me, and to care for my wellbeing.
Terms and conditions*
- I agree to the My Access Clinics terms and conditions and the privacy policy.
You can withdraw your permission at any time by contacting ukprivacy@myaccessclinics.com

Any information you share with us in this form will never be shared with a third party.

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Based on the information you have provided us so far, you are eligible for an assessment. Let’s continue with some contact details.
Contact Details*
- I'm a patient
- I'm a carer or guardian of the patient
Carer or Guardian Details
In all other cases, we’ll need to speak directly to the patient. If they have any difficulty communicating, please give us guidance on the best time to call them if you’d like to be present to assist them.
Legal guardianship
- I hold legal guardianship and have consent of the patient. If so, we will contact you directly.
Carer/ Guardian Name*
First Last
Carer/ Guardian Email*
Carer/ Guardian Phone*
Please enter a valid UK phone number. It should start with 0 or +44, and be at least 11 digits long.
Patient Details
Name*
First Last
Email*
Phone Number*
Please enter a valid UK phone number. It should start with 0 or +44, and be at least 11 digits long.
Address*
Street Address Address Line 2 City Postcode
Best time to call and arrange a consult*

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Your personal GP's details
Doctor's Name*
Medical Practice name*
Medical Practice phone number*
Please enter a valid UK phone number. It should start with 0 or +44, and be at least 11 digits long.
Contacting the doctor*
- I consent to MyAccess Clinic contacting the doctor directly to verify medical records.
Form is correct*
- I confirm all information I have provided in this form is correct

Unfortunately, based on the information you shared, you don’t yet meet the criteria that would allow us to treat you with Medical Cannabis.

Why Am I Not Eligible?

Because Medical Cannabis can’t be prescribed as a 'first-line' treatment, you need to have tried a minimum of two treatments (licensed medications) prescribed by a doctor to manage the condition, both of which have provided inadequate relief.

What Should I Do Next?

Visit your doctor to discuss other first-line treatment options as a starting point.

How Can MyAccess Clinics Help?

We would be happy to reach out to you in another two months to see how you’re progressing. If you’d like us to do so, enter your contact details below.
Name*
First Last
Email*
Patient or carer*
- I'm a patient
- I'm a carer or guardian of the patient
Name
This field is for validation purposes and should be left unchanged.

Update COVID-19

Before we finalise your eligibility...

Carer or Guardian Details

Patient Details

Medical details

Your personal GP's details

Why Am I Not Eligible?

What Should I Do Next?

How Can MyAccess Clinics Help?