Medical Cannabis Intake Form **WE CANNOT CERTIFY ANYONE UNDER THE AGE OF 21** Name Are you a resident of UT? YesNo Phone (Note: By submitting your phone number you accept and opt-in to receive text messages from Cache Ketamine) Email Last 4 of SSN Birthdate What is your qualifying condition? How long have you had your condition? Do you have any medical records that may be helpful to us? Have you tried any treatments for relief? If yes, please specify: Current medication list: Return to cannabis page
