Please read each item below and sign at the bottom of this form to indicate you understand the information regarding the risks and side effects of using marijuana. I agree to tell the attending physician if I do not understand any of the information provided.
1. I understand that the cultivation, possession and use of marijuana, even for medical purposes, are currently ILLEGAL UNDER FEDERAL LAW.
2. Under federal and state law, it is not permitted to use or possess marijuana within 1000 feet of a daycare or school. I agree not to do so.
3. I agree not to use marijuana while under the influence of alcohol.
4. I understand that it is against the law to drive a vehicle while using marijuana and that doing so will result in a DUI for driving under the influence.
5. I agree to tell the attending physician if I have ever had symptoms of depression, been psychotic, attempted suicide or had any other mental problems. I also agree to tell the attending physician if I have ever been prescribed or taken medicine for any of the conditions stated above. Furthermore, I understand that the attending physician does not suggest nor condone that I cease treatment and/or medication that stabilize my mental or physical condition.
6. I agree to immediately stop using marijuana and inform the physician in the event I become suicidal, homicidal, paranoid, or have an increase in any of these symptoms.
7. There are few known interactions between marijuana and medications or other herbs. However, very few interactions between herbs and marijuana have been studied. I agree to tell my attending physician if I am using any herbs, supplements, or other medications.
8. Some users might develop a tolerance to marijuana. This means higher and higher doses are required to achieve the same clinical effect. It is recommended for doctors to have an intermission with drug for at least 3 weeks every 3-4 months. If I think I may be developing a tolerance to marijuana, I will notify my attending physician.
9. Should respiratory problems or other ill effects be experience in association with the use of medical marijuana, I agree to discontinue its use and report any or report such problems or effects to the attending physician. Although smoking marijuana has not been linked to lung cancer, smoking marijuana can cause respiratory harm, such as bronchitis. Many researchers agree that marijuana smoke can cause respiratory harm, such as bronchitis. Many researchers agree that marijuana smoke contains known carcinogens (chemicals that can cause cancer), and that smoking marijuana may increase the risk of respiratory diseases and cancers of the lungs, mouth, and tongue. I have been advised that cannabis (medical marijuana) smoke contains chemicals known as tars that may be harmful to my health. Vaporizers may substantially reduce many of the potentially harmful smoke and toxins that are normally present in marijuana smoke.
10. Marijuana varies in potency. The effects of marijuana 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, hacking cough, disturbances to heart rhythms, and numbness in the limbs.
11. The efficacy and potency of marijuana varies widely depending on the marijuana strain and ingestion method. Under federal law, the attending physician is unable to discuss dosage.
12. I agree to use birth control while using marijuana. In the event I become pregnant, I agree to immediately discontinue use of marijuana and contact the physician. (Females only)
13. Cannabis is not regulated by the USFDA and therefore may contain unknown quantities of active ingredients, impurities, and/or contaminants.
14. I intend to obtain and use medical marijuana in the State of New York for my medical condition should medical marijuana be recommended for my condition.
15. I understand that side effects may occur while I am taking medical marijuana which can include but are not limited to: short-term memory loss, anxiety/nervousness, irregular heart beat, dry mouth, slower reaction time, impairment of motor skills coordination, poor physical coordination, hunger, loss of appetite, dizziness, cough, dependency, confusion, impaired vision, feeling of euphoria, tiredness or drowsiness, headache, nausea or vomiting, apathy, change in sleeping patterns, numbness, laryngitis, bronchitis, depression, agitation or irritability, trouble concentrating, high or low blood pressure, sedation, difficulty completing complex tasks, paranoia or psychotic symptoms (i.e., delusions), suppression of immune system, talkativeness
I understand there may be benefits and risks associated with marijuana use that have not been identified.
If I start taking medical marijuana, I agree to immediately tell my physician if I: start to feel sad or have crying spells, lose interest in my usual activities, have changes in my normal sleep patterns, lose my appetite, withdraw from family and friends, become more irritable than usual, become pregnant or start breastfeeding, become unusually tired.
Your personal statement regarding the provided facts:
I confirm that the information provided by me regarding my diagnosis and medical records is true and correct.