Application Form Name : Email : Street Address : Mailing Address (if different) Mobile Number : Other Phone Number : Gender : Male Female Other Service Tier Requested : Standard Package - $75.00 Complete Package - $200 Paid Date: Payment Method: Stand-Alone Medical Conditions that Qualify for NH Therapeutic Cannabis Generalized anxiety disorder Moderate to severe chronic pain Moderate or severe post-traumatic stress disorder Any debilitating or terminal medical condition or symptom your medical provider believes the benefits are likely to outweigh the risks Autism spectrum disorder Opioid use disorder with associated symptoms of cravings and/or withdrawal Severe Pain Qualifying Diagnoses Acquired immune deficiency syndrome Alzheimer’s disease Amyotrophic lateral sclerosis Cancer Chronic pancreatitis Crohn’s disease Ehlers-Danlos syndrome Epliepsy Glaucoma Hepatitis C Lupus Multiple sclerosis Muscular dystrophy One or more injuries or conditions that have resulted in one or more qualifying symptoms Parkinson’s disease Positive status for human immunodeficiency virus Spinal cord injury or disease Traumatic brain injury Ulcerative colitis Possible qualifying medical conditions/symptoms Agitation of Alzheimer’s disease Moderate to severe vomiting Cachexia Seizures Chronic pancreatitis Chemotherapy induced anorexia Severe pain Constant or severe nausea Severe, persistent muscle spasms Elevated intraocular pressure Wasting syndrome Moderate to severe insomnia Submit
