Transferring Clinics

Eligibility Assessment

By submitting my application, I understand that elios clinics will receive my information and may reach out to me via phone, email, or SMS regarding my treatment. *

I consent to receiving emails communication and updates from elios clinics on a regular basis. *

Are you transfering from another medical cannabis clinics? *

YesNo

Name of the clinic *

Account Information

Are you completing form on behalf of some one else? *

NoYes

Please enter your Name *

Your relationship with the patient? *

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Title *MrMissMrsMsMxDrMasterOther

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Other *

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First Name *

Last Name *

Date Of Birth *

Gender *FemaleMaleAFABAMABSpecify

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Are you currently pregnant? *

YesNo

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Specify *

Email Address *

Phone Number *

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Address *

Street address *Street address line 2

City *

State

Postcode *

Country *Please selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

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Where did you hear about us? *My doctor or healthcare professionalRecommended by a patient of Elios ClinicsPodcast / RadioGoogle SearchSocial MediaPress / TVLocal PharmacyOther (please specify below)

Other (Please Specify) *

What days are prefered for a Consultation booking? *

Weekday (Monday to Friday)Weekend (Saturday and Sunday)

What Times are prefered for a Consultation booking? *

Mornings (9am to 12pm)Lunch Time (12pm to 2pm)Afternoons (2pm to 6pm)Evenings (6pm to 9pm)

About your health

Reason you would like to be considered for treatment *

CancerPainPsychiatricDermatologyGastrointestinal ConditionNeurological ConditionsOther (please specify below)

Reason for treatment *

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Documents

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Upload your Discharge Letter

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Description of files needed (screen shot of NHS records, Downloaded report from NHS APP or Website, Records from GP, Letters from GP, Letters from Consultants, any other information that relates to your medical condition and history). You can add multiple files.

Please provide copy of your last prescription

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You can add multiple files

Consent

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I consent for Elios clinics to obtain my medical records and accept Terms and Conditions *

Your Signature *

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Date *

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