By completing this form, you refer yourself for the purposes of an assessment for possible medical cannabis treatment.
You are agreeing to share the following demographic and medical information with KernowCann.
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You are agreeing for KernowCann to share this information with the medical and administrative teams at MyAccess Clinics under whom we care for our patients as part of a shared care agreement.
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You are agreeing for us to store your information in line with the Data Protection Act 2022 and under the Caldicott Principles and the terms laid out in our privacy policy.
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You confirm that you are completing your medical history truthfully, accurately and completely and that should that information change during the initial assessment you will notify us.
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You confirm that you are over 18 years of age.
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You agree and understand that if your referral should progress to initial consultation you will need to provide KernowCann and MyAccess Clinics with a summary care record from your GP in order for us to provide you with safe care.
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You understand that we will need to discuss your case with you, and that you may not be suitable for medical cannabis based on your medical or psychiatric history.
