TherapYOUtics - Apply for Virginia Medical Marijuana Card

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Medical Marijuana Questionnaire

Complete the form below to get started. The information provided will help us assess your eligibility and ensure a smooth certification process.

Enter your full name as it appears on your drivers license*

Enter your email*

I have read and accepted the terms of service and privacy policy

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Personal Information & Certification Details

Collect basic info and certification type to begin the process.

Date of Birth

Phone Number

Full Address

Certification Type:

Original Certification (First time)

Renewal Certification (Had a card in VA before)

Referral Type

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Cannabis Use History & Medical Conditions

Understand the patient’s experience and medical qualifications.

Have you ever used cannabis before?

Have you had a reaction to cannabis in the past?

If you answered "Yes" to a reaction to cannabis in the past, please explain.

Other Medical Conditions:

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Health Assessment

Evaluate overall health risks and medication use.

Do you take any medications?

List your medications:

Any known allergies?

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Additional Info & Final Review

Complete your submission and help us better serve you.

Renewals Only – Effectiveness Rating:
On a scale of 1 to 5, how well has cannabis helped your condition?

How did you hear about us?

Exclusionary Criteria

To ensure that medical marijuana is appropriate for your health, you will be excluded from consideration for a prescription with therapYOUtics if you meet any of the following criteria:
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1. Age: Patients must be 18 years of age or older to be considered for medical marijuana treatment with therapYOUtics, unless medically necessary.
2. Pregnancy or Breastfeeding: If you are currently pregnant or breastfeeding, you are not eligible for medical marijuana prescriptions.
3. Psychiatric Conditions: Patients with a history of schizophrenia or bipolar disorder are not eligible for medical marijuana treatment, as it could trigger psychosis/mania.
4. Allergic Reactions to Marijuana: If you have a known allergy to marijuana or any of its components, you will not be eligible for a prescription.
5. Active Substance Abuse: If you are undergoing active treatment for substance abuse or have a history of substance abuse disorder that is not properly managed, you may not be eligible for medical marijuana treatment.
6. Involvement in Legal Restrictions: If you are under any legal restrictions preventing the use of marijuana, such as probation or parole terms, you may not be eligible for a prescription.

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