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Medical Marijuana Consent Form
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Sections to Complete
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Part A: Must be completed for all medical marijuana patients
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Schedule
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a. The Federal Government's classification of marijuana as a Schedule I controlled substance.
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Class of Drug
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When in the possession of medical marijuana, the patient or the patient's caregiver must have his or her medical marijuana use r
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b. The approval and oversight status of marijuana by the Food and Drug Administration
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FDA
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c. The potential for addiction.
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Studies
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d. The potential effect that marijuana may have on a patient's coordination, motor skills, and cognition, including a warning
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Effects
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e. The potential side effects of medical marijuana use.
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Side Effect
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Mxing
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Alcohol
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Contacting Doctor
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Contacting Office
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f. The risks, benefits, and drug interactions of marijuana.
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Signs of withdrawal can include:
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Withdrawal
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Overdose
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Overdosing
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Interatcion
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Interactions
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Risk of Bleeding
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Risk
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Serious Risks
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Serious Risk
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g. The current state of research on the efficacy of marijuana to treat the qualifying conditions set forth in this section.
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Cancer
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Cancer
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Epilepsy
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Epilepsy
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Glaucoma
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Glaucoma
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Positive status for human immunodeficiency virus
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HIV
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Acquired immune deficiency syndrome
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AIDS
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Post‐traumatic stress disorder
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PTSD
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Amyotrophic lateral sclerosis
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ALS
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Crohn's disease
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Crohn's
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Parkinson's disease
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Parkinson's
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Multiple sclerosis
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MS
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Medical conditions of same kind or class as or comparable to the above qualifying medical conditions
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Condiions
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Terminal conditions diagnosed by a physician other than the qualified physician issuing the physician certification
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Terminal
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Chronic nonmalignant pain
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Pain
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h. That the patient's de‐identified health information contained in the physician certification and medical marijuana use
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Registry
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PART B: Certification for medical marijuana in a smokable marijuana for a patient under 18 with a diagnosed terminal condition.
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Read Carefully
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Respiratory Health
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Respiratory Health Facts
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Cognitive and Psychosocial Development
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Cognitive and Psychosocial Development Facts
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Addiction
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Addiction
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Part C
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Acknowledgement of contaminant risks.
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Contaminant Risks
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Respiratory Health.
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Exposure
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Information regarding health risks of 2nd and 3rd hand smoke to other household members.
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Around Others
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Dangers of smoking marijuana in households where oxygen is in use.
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Around Oxygen
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Self‐dosing, if permitted.
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Dosing
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Part D: Must be completed for all medical marijuana patients
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Initials for ALL Patients
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All Patients
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Conclusion
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New Header
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Patient (print name)
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Patient signature or signature of the parent or legal guardian if the patient is a minor:
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Date
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