Utah PatientsSubsidy Application Subscribe First Name *Middle NameLast Name *I have a valid Utah Medical Cannabis Card *YesNoPatient ID Number *Preferred Pharmacy *Dragonfly Wellness (Salt Lake City)Perfect Earth Modern Apothecary (North Logan)Perfect Earth Modern Apothecary (Ogden)Wholesome Co (Bountiful)Deseret Wellness (Provo)Deseret Wellness (Park City)Beehive Farmacy ( SLC)Beehive Farmacy (Brigham City)Cannabist (Springville)Email Address *Phone *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabwePlease Check all that apply:I am a VeteranI am a Senior CitizenI am Physically DisabledI am Currently Receiving DisabilityI am Currently Receiving Social SecurityI am Currently Receiving Government Financial AssistanceI am Considered Terminal by a Medical ProviderPlease explain why you would like to be considered for the Utah Patient Subsidy Program? *For how long are you seeking assistance? *TemporaryOngoingDo you have a Medical Cannabis qualifying condition? *YesNoQualifying medical condition:What conditions or symptoms do you use cannabis for? *Please list all conditions whether they are qualifying conditions or not. Are you currently receiving hospice care? *YesNoAre you currently employed? *YesNoDo you have health insurance? *YesNoDo you have children under the age of 18 living in your home? *YesNoWhat form of cannabis do you currently medicate with? *Raw FlowerVape CartridgesTinctures/Oral SpraysCapsulesEdible ChewsTopicalsConcentrates (Wax, Rosin, etc)Check all that apply. What form of cannabis is MOST EFFECTIVE for your condition? *Raw FlowerVape CartridgesTinctures/Oral SpraysCapsulesEdible ChewsTopicalsConcentrates (Wax, Rosin, etc)Select all that apply. Where do you currently get your cannabis from?Would you be able to contribute any amount of money towards your medication? *YesNoHow much would you be able to contribute? *USDWould you be willing and able to volunteer/ assist within the subsidiary program? *YesNoPossiblyDo you require home- delivery? *YesNoPossiblyDo you have a caregiver? *YesNoDo you need a caregiver? *YesNoDo you feel you are getting the maximum therapeutic benefits from medical cannabis? *YesNoWould you want to speak with a QMP/Pharmacist to assist you to maximize the therapeutic benefits of Cannabis?YesNoPlease list any other information that you would like us to know or feel is important for us to know about your conditions, financial situation, etc.. *Upload any financial or medical information that you feel would be beneficial to us. Drag and Drop (or) Choose Files(Optional)HIPPA Information Release *By signing this document I declare that the information I have provided in this application and in all of the included supporting documents is accurate, true to the best of my knowledge and is provided of my own free will. I have read and I understand the program requirements as described in the application instructions. I understand that completion of this application does not guarantee that I will receive services. I understand that the Utah Patients Subsidy Program services are provided at Utah Patients Coalition discretion and that UPC may modify the program at any time. The information provided on this form will be kept confidential and will be used strictly to determine eligibility for the UPSP program. No identifying information will be released without written permission from the Applicant. Submit ApplicationPlease do not fill in this field.