EliosCare Patient Portal

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 email communication and updates from Elios Clinics on a regular basis. *

I consent for Elios Clinics to obtain my medical records and accept Terms and Conditions. This is required so we can safely review your treatment and support you with the right care. *

Read the Terms and Conditions before you submit this form.

Are you transferring from another medical cannabis clinic? *

YesNo

Are you completing the form on behalf of someone else? *

YesNo

Title *

First name *

Last name *

Date of birth *

Gender *

Email address *

Phone number *

Street address *

Street address line 2

City *

Postcode *

Country *

Where did you hear about us? *

Upload your discharge letter

No files selected yet.

Please provide a copy of your last prescription

No files selected yet.

Your signature *

Date *

Switch clinics form