FOR INDIVIDUALS WHO ARE PENNSYLVANIA RESIDENTS AGE 18 AND OLDER
IF YOU ARE UNDER 18, PLEASE STOP HERE.
Before becoming a medical cannabis patient of Dr Sam 420, we need to ensure that an individual meets the criteria set forth by the Pennsylvania Department of Health. Part of these crtieria include being a legal resident of Pennsylvania and having one of the pre-approved medical conditions.
This webform is HIPAA secure. You also acknowledge that HIPAA rules and regulations are followed by Dr. Urick and My Way Medical, LLC. We will NOT release your information to any other entity (physician, clinician or healthcare facility) without your explicit permission. Your emergency contact listed will be able to receive information regarding your condition or contacted if we are unable to reach you.
By entering your name below, you acknowledge that you are a resident of Pennsylvania and that you meet criteria for one of the Pennsylvania Department of Health approved medical conditions for medical marijuana. You acknowledge that the patient-physician relationship will not officially commence (You will not officially become a patient under our care) until you arrive in our office/telemedicine appointment for your appointment and we receive payment for your initial visit.
• You acknowledge that you have read the consent form on our website and have electronically signed them and submitted to our office and understand the medical marijuana policies of both state and federal law.
• You acknowledge that we are certifying you for medical marijuana in the state of Pennsylvania. This division of our practice does not provide primary care services, prescribe or refill prescription medications, or serve as a primary care physician.
• Some employers may ask for proof that you can work safely when using medical marijuana. We can acknowledge that you are certified but cannot give a time frame for them on how long the THC will remain in your system or what effect it will have on impairement (just as we cannot commment on how long a medication like ativan or xanax (benzodiazepines) can impair you).
• WHEN COMPLETING THE FORM, YOU WILL NEED TO FILL IN EACH FIELD MARKED BY AN ASTERISK *. Your submission is completed if a screen pops up after submission stating "THANK YOU FOR YOUR SUBMISSION" with a GREEN CHECK MARK.
• If you are pregnant, you will not be able to receive medical marijuana until after your baby is born.
• If you are diagnosed with Schizophrenia, you will not be a candidate for medical marijuana certification as this has been shown to worsen the underlying diagnosis.