Medical Marijuana Consent 1 by eyv84599



                                      To be completed by the patient and signed by the attending physician
Read each item below and initial in the space provided to indicate that you understand and agree to each item. Do not sign this agreement and do not use
medical marijuana if you have questions about or do not understand the information you have received.

I, ________________________________________________________ (patient’s name), understand that medical marijuana is a medicine used in
treating the suffering caused by serious and debilitating medical conditions which include but are not limited to:

     •    Cancer
     •    Human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS)
     •    Arthritis
     •    Glaucoma
     •    Migraine
     •    Anorexia
     •    Persistent muscle spasms, including, but not limited to, spasms associated with multiple sclerosis
     •    Seizures, including, but not limited to, seizures associated with epilepsy
     •    Cachexia (weight loss, wasting of muscle, loss of appetite, and general debility that can occur during chronic disease)
     •    Severe or chronic pain
     •    Severe nausea

Additionally, medical marijuana is used in the treatment of other chronic or persistent medical symptoms that:

     •    Substantially limit the ability of the person to conduct one or more major life activities as defined in the Americans with Disabilities Act of 1990 (Public Law
     •    If not alleviated, may cause serious harm to the patient’s safety, or physical or mental health

Initials: _______________

I have been advised that the use of cannabis (medical marijuana) may affect my coordination and cognition in ways that could impair my ability to drive.
I agree not to operate heavy machinery, drive, or engage in potentially hazardous activities while under the influence of cannabis.

Initials: _______________

Although smoking marijuana has not been linked to lung cancer, smoking marijuana can cause respiratory harm, such as bronchitis. Many researchers
agree that marijuana smoke contains known carcinogens (chemicals that can cause cancer), and that smoking marijuana may increase the risk of
respiratory diseases and cancers of the lungs, mouth, and tongue. I have been advised that cannabis (medical marijuana) smoke contains chemicals
known as tars that may be harmful to my health. Vaporizers may substantially reduce many of the potentially harmful smoke toxins that are normally
present in marijuana smoke.

Initials: _______________

I understand that side effects may occur while I am taking medical marijuana. These effects have been explained to me. Side effects of medical marijuana
can include, but are not limited to:

     •    Euphoria                                                                               •     Anxiety
     •    Difficulty in completing complex tasks                                                 •     Impairment of short-term memory
     •    Inability to concentrate                                                               •     Impairment of motor skills, reaction time and physical coordination
     •    Sedation                                                                               •     Confusion
     •    Alterations in the perception of time and space                                        •     Dysphoria
     •    Tachycardia (fast heart beat) and heart palpitations                                   •     Paranoia
     •    Low blood pressure                                                                     •     Psychotic symptoms (e.g., delusions, hallucinations)
     •    Dizziness                                                                              •     Suppression of the body’s immune system
     •    Increased talkativeness

Initials: _______________                                                                Provider Initials __________________

I agree to contact my physician immediately if I have any of have any of the following side effects:
     •    Nausea
     •    Vomiting
     •    Disturbances to heart rhythms and numbness to the limbs
     •    Hacking cough

Initials: _______________

                                       To be completed by the patient and signed by the attending physician
For some patients, chronic marijuana overuse can lead to laryngitis, bronchitis and general apathy .Initials: _______________

I understand that some patients can become dependent on marijuana. This means they experience withdrawal symtoms when they stop using marijuana.
Signs of withdrawal symptoms, while generally mild, can include:

     •    Feelings of depression, sadness or irritability
     •    Restlessness or mild agitation
     •    Insomnia
     •    Sleep disturbances
     •    Unusual tiredness
     •    Trouble concentrating
     •    Loss of appetite

Initials: _______________

Although marijuana does not produce a specific psychosis, the possibility of exists that it may exacerbate schizophrenia in persons predisposed to that

Initials: _______________

I understand that using marijuana while under the influence of alcohol is not recommended.          Initials: _______________

I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and therefore may contain unknown quantities of
active ingredients, impurities, and/or contaminants.

Initials: _______________

I understand that I can get a DUI for driving under the influence.                                  Initials: _______________

I understand that I am not permitted to smoke within 1000 feet of a daycare or school.              Initials: _______________

I understand that I am not permitted to smoke where I cannot smoke tobacco.                          Initials: _______________

I certify that I have read this document and declare under penalty of perjury that the information contained herein is true, correct, and

Patient signature: ___________________________________________________________ Date __________________________

Patient name (print): ________________________________________________ Telephone ______________________________

Patient Address: ___________________________________________________________________________________________

I have fully explained to the patient, _____________________________________________________ , the nature and purpose of
medical marijuana treatment, including its benefits and possible side effects.

I have asked the patient if he/she has any questions regarding his/her treatment with medical marijuana and I have answered those
questions to the best of my ability.

Attending Physician Signature: _____________________________________________ Date ____________________________
                                  Wallace S. Marsh MD

To top