Patient Information:

 

Medical History

 

Marijuana History:

  • This information will be used to help create a recommendation that can be used as a guide to help provide information on what types and delivery methods would be most appropriate to help treat the certifying condition. It is only a recommendation and in no way replaces your doctors advice. The content of this form is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health providers with any questions you may have regarding a medical condition.
 

Caregiving

 

Signature

 

Verification