PA Medical Marijuana Evaluation Forms and Consents

Are you allergic to any medications?No

Yes (please complete the table below)

I understand that medical marijuana is a medicine used to treat the suffering caused by serious and debilitating medical conditions.

I understand that medical marijuana use for treatment of these conditions has not been approved by the Federal Drug Association (FDA) I have been advised and understand that the use of cannabis (medical marijuana) may affect my coordination and cognition in ways that could impair my ability to drive, operate heavy machinery, or engage in potentially hazardous activities. 

Although smoking marijuana has not been linked to lung cancer, marijuana smoke can contain known carcinogens (chemicals that can cause cancer), and smoking marijuana may increase the risk of respiratory disease and cancers of the lungs, mouth and tongue. I have been advised that marijuana smoke also contains 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. Smoking marijuana is not allowed. Marijuana varies in potency.

The effects can also vary with the delivery system. Estimating the proper marijuana dosage is very important. Symptoms of marijuana overdose include but are not limited to nausea, vomiting, disturbances to heart rhythms, numbness in the limbs, and/or hacking cough. Signs of withdrawal, while generally mild, can include feelings of depression, sadness or irritability, restlessness or mild agitation, insomnia, sleep disturbances, unusual tiredness, troubled concentration, and/or loss of appetite. For some patients, chronic marijuana overuse can lead to laryngitis, bronchitis and general apathy. I understand that side effects may occur while I am taking medical marijuana. These side effects include but are not limited to: headache, decreased blood flow to the brain, altered body temperature, fatigue, inattention, aggressiveness, sedation, anxiety or panic, inability to concentrate, decreased verbal skills, nystagmus, decreased coordination, suicidal ideation, increased food consumption and weight gain, rapid heart rate, reduced muscle strength, altered libido / impotence, hallucination confusion, paranoia, cuphoria, amotivational syndrome, increased talkativeness, hunger, addictive behaviors, depersonalization, reduced testicular size.

I understand that using marijuana while under the influence of alcohol or other controlled substances is not allowed. Using marijuana may decrease reproduction in men as well as women. Women who are trying to conceive, or who are pregnant, or breastfeeding must NOT use marijuana. Marijuana may increase risk of leukemia in children whose mothers smoked marijuana during pregnancy. Marijuana may also increase risk of an aggressive form of testicular cancer in men.

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

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.

I agree to tell the doctor if I have ever had any symptoms of depression, been psychotic, attempted suicide, or had any other mental problem. I also agree to tell the doctor if I have ever been prescribedor taken medications for any other problems.

I understand that the doctor does not suggest nor condone that I cease treatment of medications that stabilize my mental or physical condition.

I affirm that I have a serious medical condition that adversely affects my quality of life. I have found or am interested in finding whether cannabis (medical marijuana) provides substantial relief and improvement in my condition.

If I start taking medical marijuana, I will tell the doctor if I experience any adverse symptoms/side effects. I understand that the attending physician / nurse practitioner / physician assistant / medical provider, staff and representatives of this practice are neither providing nor dispensing cannabis, nor are they encouraging any illegal activity in my obtaining medical marijuana. Iunderstand that in order to conduct an appropriate evaluation, the doctor must take my medical history history.

At this time, cannabis is an alternative or complementary treatment. I understand to receive a recommendation for cannabis use, I should have tried, or be willing to consider trying, at least one other recommended treatment from a medical provider. I have obtained or attempted to obtain medical records pertaining to my condition or currently have medical records pertaining to my condition and agree to be referred for further evaluation as the physician deems necessary.

 

I understand I am not eligible for any fee refund for any reason.

 

1. I understand that should I be given a recommendation for medical use of cannabis I must be regularly followed up by a doctor and appear for re-evaluation at a date specified by the attending physician/nursc practitioner/medical provider.

2. I request a consultation by an attending physician/nurse practitioner/medical provider for the sole purposes of confirming my qualifying medical condition and determining the appropriateness of medical cannabis treatment. I. the undersigned, understand that there are no representations about the medical efficacy of cannabis.

3. I understand that the doctor is addressing specific aspects of my medical care, and, unless otherwise stated is in no way establishing herself as my primary care provider. The attending physician/nurse practitioner/medical provider is only rendering an opinion regarding the therapeutic indication of the use of medical marijuana.

4. My heirs, assigns, or anyone acting on my behalf, hold the attending physician/nurse practitioner/medical provider and his/her principles, agents and employees, free of and harmless from any responsibility and liability resulting from the use of cannabis. In case any claim or disputes arise, I agree to arbitrate such claims/disputes and I agree that Pennsylvania law will govern such claims/disputes.

5. Further, if any of these clauses is deemed invalid, the other clauses will remain in full force and effect.

1. I confirm that I have been given a patient packet, have reviewed its contents in their entirety and have had an opportunity to ask all questions prior to signing below.

2. I have been counseled by the doctor regarding risks and potential benefits and agree to use medical marijuana only as directed for medical purposes.

3. I will call the office if I have any problems or concerns regarding this medication.

4. I understand that the doctor is not implying or suggesting that medical marijuana should be a substitute for any treatment prescribed by any other physician.

Physicians provide medical evaluation and consultation regarding recommendations for medical cannabis/marijuana only. Services for which fees may be collected include medication consultations and evaluations and completion of the certification process as required by the state of Pennsylvania. Payment of fees does NOT entitle, ensure, or warrant that (1) the patient will receive a medical cannabis recommendation or (2) any recommendation given will be written for twelve months. Indications for the medicinal use of marijuana in Pennsylvania include: amyotrophic lateral sclerosis (ALS/Lou Gehrig's disease), anxicty disorders, autism, cancer including remission therapy, Crohn's disease, damage to the nervous tissue of the central nervous system (brain/spinal cord) with objective neurological indication of intractable spasticity and other associated neuropathies, dyskinetic and spastic movement disorders, epilepsy, glaucoma, HIV/AIDS, Huntington's disease, inflammatory bowel disease, intractable seizures, multiple sclerosis, neurodegenerative diseases, neuropathies, opioid use disorder for which conventional therapeutic interventions are contraindicated or ineffective, or for which adjunctive therapy is indicated in combination with primary therapeutic interventions, Parkinson's disease, post- traumatic stress disorder (PTSD), severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain, sickle cell anemia, terminal illness, and tourette syndrome. 

After evaluation by the state-approved medical doctor, all patients are instructed to follow-up with their primary care physician, mental health provider or other healthcare providers for continuing care.

All patients using medical cannabis are advised that it is unlawful to drive or operate heavy machinery/ equipment under the influence of cannabis.

Physician does not recommend, endorse or work with any medical marijuana dispensary. It is the patient's responsibility to seck out a satisfactory dispensary. Any product quality concerns should be addressed with the on-staff pharmacist at the chosen dispensary. Physicians and staff are not liable for any quality-related concerns or negative effects related to products purchased at the dispensary.

Physicians may deny the recommendation in appropriate cases. I understand I am not entitled to a refund if I do not qualify for recommendation or fail to meet guidelines needed to maintain this recommendation

 

I hereby certify that I have read and acknowledge all of the above.

Patient Signature (Full Legal Name)