What therapies have you tried? Please check all that apply. Please rate the effectiveness on a scale of 1 to 3 (1 Not Effective, 2 Effective, 3 Very Effective)
Medical Documents Release Forms.
Cannascribe will require your medical records. If your doctor is unable to assist you or if you cannot get access to your physician, medical records that support your diagnosed ailment will need to be collected in one of two ways; on your own from your doctors receptionist by requesting your medical history, or we can obtain them with a completed Release Form. The completed Release Form can be submitted by you or Cannascribe can submit it on your behalf. Please choice the best option below.
I understand that this Release and Acknowledgment contains IMPORTANT information about medical cannabis that the assessing physician requires that I acknowledge and understand before he/she may issue a prescription and/or authorization for use of medical cannabis.
I further understand that the consulting physician will not necessarily be assuming care for me. He/She will, however, assess and evaluate the appropriateness of my request to use medical cannabis to assist in treating the conditions and associated symptoms that I believe; from my own personal experience, medical cannabis to be helpful in treating.
I accordingly confirm that the assessing physician will be my medical practitioner for the sole purpose of medical cannabis authorization and/or prescriptions.
I agree not to make any claim or commence any legal proceedings against the assessing physician, his/her practice, my family physician or any other involved physicians (such as specialists) in relation to:
1. my use of cannabis as a medicine; and
2. my Application or, prescription for possessing, obtaining and using medical cannabis.
I am well aware that physicians generally agree that medical cannabis;
• May distort perception (sights, sounds, touch, time);
• May impair memory and learning
• May impair coordination
• May impair thinking and problem-solving
• May increase heart rate and reduces blood
• May produce anxiety, fear, distrust or panic.
I am well aware there is considerable debate and a great lack of consensus among physicians about;
• The appropriate medical use of cannabis;
• The appropriate dosage for medical cannabis;
• The risks of smoking medical cannabis as compared to vaporizing or ingesting medical cannabis;
• The risks of smoking whole plant medical cannabis as compared to extracting the medicinally active cannabinoids;
• The long-term health and psychological risks associated with the use of medical cannabis;
• The degree to which regular consumption of medical cannabis;
• May contribute to pulmonary infections and respiratory cancer;
• May damage the cells in the bronchial passages which protect the body against inhaled microorganisms and decrease the ability of the immune cells in the lungs to fight off fungi, bacteria, and tumour cells. For patients with already weakened immune systems, this means an increase n the possibility of dangerous pulmonary infections, including pneumonia;
• May weaken various natural immune mechanisms, including macrophages and T-cells.
• May correlate in some cases with mental illness, such as a bipolar disorder and schizophrenia
I am further well aware that the above listed medical concerns are further compounded by the lack of consistency and uniformity in available medical cannabis products. With conventional drug products, I generally consume a medication of a precise known molecular quantity. I recognize that raw plant Medical Cannabis does not work this way. I appreciate that I will get varying compositions of different cannabinoids and varying proportions of different cannabinoids from the strain of plant.
I further appreciate that there is significant uncertainty regarding the consistency of medical cannabis, which further complicates and compounds the practical issue of medicating with an inconsistent drug product like medical cannabis.
I am aware that ingesting a high dose of medical cannabis can cause nausea and disorientation.
In seeking medical cannabis treatment I confirm I have consulted with a physician’s alternative and conventional treatment options for my condition.
Despite all these medical concerns, debates and practical issues, I honestly believe that for the treatment of my condition(s) and symptom(s) the benefit of medicating with medical cannabis outweigh the risks.
This is my decision and I also do not support any claims made by my family, friends or other interested parties against said clinic and physicians.
I hereby release the assessing physician, his/her clinic, my family physician, and any other involved physicians from any and all actions, claims, causes of actions, complaints (even by family and friends) and demands for damages, loss, or injury whatsoever arising directly or indirectly as a consequence to my use of medical cannabis.
This release from liability is to be binding on heirs, executors and assigns. I also consent to the disclosure, sharing and use of my personal information and medical data by the assessing physician, Cannascribe and my licensed producer. The information may be used to contact, address and register the patient and for analysis and research to better help our members.
I understand and acknowledge that while the assessing physician may execute a declaration that I stand to potentially benefit from medical cannabis, the assessing physician will not serve as my primary care physician. As such, I agree to seek regular medical care from my primary care physician and that the assessing physician will only deal with assessing his/her support from my medical cannabis use. I also consent to the assessing physician notifying any specialists have seen my decision to use medical cannabis and I accept any consequences of such notification.