CONSENT:
We are establishing a physician-patient relationship to determine whether a recommendation for the safe use of medical marijuana can be made and NOT for any other purpose. You are advised to consult with your primary care provider at least once a year for re-evaluation of the diagnosis and treatment plan.
I understand that the physician is NOT providing or recommending medical treatment. The physician is evaluating me to determine whether I have a chronic debilitating condition as defined by Article XVIII and SB 109
I understand that an opinion from the physician that I am qualified for the use of medical marijuana as defined by Article XVIII and SB 109 is NOT a recommendation as to how, when, what form or how much marijuana product I use. While these issues may be discussed at the time of my medical card evaluation, any and all decisions regarding these matters should be made after consultation with my primary care provider.
I understand that the sole purpose of this examination is to determine whether I am qualified to receive a Colorado medical marijuana card. The evaluation is based on constitutionally outlined conditions and diagnoses as defined by Colorado Constitution Article XVIII and SB-109.
I understand that the physician evaluating me can only make a provisional diagnosis for my chronic debilitating medical condition. The physician’s opinion as to whether I qualify for the use of medical marijuana is based on my medical history, current medical status, drug or medication abuse, physical exam, medical records (if available), form of marijuana used, whether I grow my own plants and my yield per plant.
I understand that I am NOT receiving a comprehensive medical examination as one would expect from their primary care provider. The examination is limited to factors and/or conditions related to my receiving a medical card allowing me to purchase medical marijuana. It is not intended to replace, supersede and/or modify any treatment or recommendation of my primary care provider.
I understand that it is my responsibility to ensure that my primary care provider is aware of and approves of my intentions regarding the use of medical marijuana.
I understand that the physician providing this medical evaluation is available for follow-up care for any and all matters related to my use of medical marijuana.