Application Form

Referred By (to accommodate company names as well as individuals)(Required)

Full Name

Name(Required)

Enter Your Full Name

Email(Required)

Street Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Number(Required)

Other Phone Number

Genter(Required)

Male

Female

Other

Date of Birth(Required)

Service Tier Requested(Required)

Complete Service Package

$200.00

(Includes Standard Service Package plus full coverage of the cost of the patient’s initial state-mandated in-person evaluation and certification office visit.)

Standard Service Package

$75.00

Includes education/instruction, pre-qualification, and referral to one or more suitable medical providers for the state-mandated in-person evaluation and certification office visit. Patient is responsible for payment of provider services.

Check at least one box from at least one of the following and all that may apply (required)

Stand-Alone Medical Conditions that Qualify for NH Therapeutic Cannabis. Check at least one box below (Required) and all that may apply:

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

Possible qualifying medical conditions/symptoms