Application | Utah Patients Coalition

First Name *

Last Name *

Email Address *

Phone Number *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Do you currently have a Utah Medical Cannabis Card? *YesNo

Medical Card Number

Please explain why you would like to be considered for the Utah Canna Care patient subsidy program? *

For how long are you seeking assistance?TemporaryOngoing

Do you have a Medical Cannabis qualifying condition?NoYes

Qualifying 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? *YesNo

Do you have a terminal illness? *YesNo

Are you currently employed? *YesNo

Do you have health insurance? *YesNo

Do you have children under the age of 18 living in your home? *YesNo

Check all that apply to you: *I Am a VeteranI Am a Senior CitizenI Am Physically DisabledI Am Receiving DisabilityI Am Receiving Social SecurityI Am Receiving Government Financial AssistanceI Qualify for Government Assistance

Where do you currently get your cannabis from? *

How much would you be able to contribute? *

USD

Would you be able to contribute any amount of money towards your medication? *YesNo

Would you be willing and able to volunteer/ assist within the subsidiary program? YesNo

Do you have a preference of a Pharmacy to get your Medicine that you feel would best suite your medical needs, such as in stock availability, forms, strains, and otherproducts each pharmacy carries?

Do you require home- delivery? *YesNoMaybe

Do you have a caregiver? *YesNo

Do you need a caregiver? *YesNo

Do you feel you are getting the maximum therapeutic benefits from medical cannabis? *YesNo

Would you want to speak with a QMP/Pharmacist to assist you to maximize the therapeutic benefits of Cannabis? *YesNo

Please 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..

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.

Utah Patients
Subsidy Application

Donate to Utah Patients

Cannabis Subsidy

Utah Patients Subsidy Application

Donate to Utah Patients

Cannabis Subsidy

Utah Patients
Subsidy Application