Medical Cannabinoids Informed Consent Form

  • Charm City Cannabis Cards/My Card Doctor.com (coming soon)

    A Telemedicine Subsidiary of Well Medical Center, PC

  • Medical Cannabinoids Informed Consent Form

    CharmCityCannabis Cards: wellmedicalcenter.com 1-800-368-9607

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    START YOUR INTAKE QUESTIONNAIRE & CONSENT FORM NOW!

    Medical Cannabinoid Therapy

    Cannabinoids are compounds found in cannabis (marijuana) that may help manage certain symptoms and conditions.

    Like any treatment, medical cannabinoid therapy has potential benefits and risks. Treatment should be viewed as a trial and continued only if it provides meaningful improvement without unacceptable side effects.

    No specific results can be guaranteed. Please discuss any questions or concerns with your healthcare provider.

    The following are some of the recognized risks for use of this substance:

    1. Psychiatric Disturbance, including but not limited to the development of schizophrenia
    2. Numbness
    3. Speech disorders
    4. Muscle disorders
    5. Drowsiness
    6. Cognitive and Memory Impairment
    7. Short-term memory

    Benefits

    The following are alleged to be the efficacy of marijuana to treat the qualifying conditions, but still require further study. Caveat: there is not much literature for study or very little evidence on these areas that cannabinoids are the cure to these illnesses:

    1. Cancer
    2. Chronic benign pain
    3. Crohn's disease
    4. Epilepsy
    5. Glaucoma
    6. Acquired immune deficiency syndrome
    7. Post-traumatic stress disorder
    8. Amyotrophic lateral sclerosis
    9. Multiple sclerosis
    10. Parkinson's disease

    Laws and Regulations

    There are laws and regulations regarding the use of cannabinoids that your practitioner has to adhere to. The following requests are considered standard best practice and help this healthcare practice, and you comply
    with these laws and regulations.

  • Do have a history of Muscle Aches/Chronic Pains/Back Pain?
  • Do have a history of anxiety or panic disorder?
  • Do you have history of substance abuse?
  • Do you have a history of suicidal thoughts or ideations?
  • Have you ever been diagnosed with schizophrenia, major depression, or other psychosis? If so, which?
  • Do you have any history of thyroid cancer or disease. If so, what type?
  • Have you ever been diagnosed with asthma or bronchitis?
  • If applicable, are you currently pregnant or breastfeeding?
  • Are you on any of the following medicines (SELECT NONE IF NONE OF THESE APPLY TO YOU)?

  • Acknowledgment

    In consideration of being allowed to consume Medical Cannabinoid, I hereby agree that during the period that I am experiencing the side effects of such use, I will not drive any vehicle or operate any heavy machinery within 8 hours.

    I understand that the intake of alcohol is not recommended and dangerous and therefore I shall not take both together.

    I agree to comply with the requirements set forth by the physician and shall not use marijuana in an unregulated manner. I likewise agree to use marijuana only as prescribed by my physician.

    I agree not to give, sell, or share the marijuana with anyone else.

    I agree to store the marijuana in my possession safely, properly, and away from the view of anyone, including children.

    I shall not take the marijuana outside the country, nor should I bring it with me for travel to any other country or state.

    I understand that if in any case my condition worsens or unusual or unknown side effects happen, I shall notify my physician immediately.

  • Date of your scheduled appointment with Dr. Butler/Well Medical Center:
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  • Birth Date
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  • Age of Consent
  • Format: (000) 000-0000.
  • Date Signed
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