MMJ Acknowledgement & Disclosure form

Name *

First Name

Last Name

Date of Birth *

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I understand that medical marijuana is a medicine used in treating the suffering caused by serious and debilitating medical conditions. These serious and debilitating medical conditions are listed below. *

-Amyotrophic lateral sclerosis (ALS) -Anxiety Disorders -Autism -Cancer, including remission therapy -Crohn’s disease -Damage to the nervous tissue of the central nervous system (brain-spinal cord) with objective neurological indication of intractable spasticity, and other associated neuropathies -Dyskinetic and spastic movement disorders -Epilepsy -Glaucoma -HIV/ AIDS -Huntington’s disease -Inflammatory bowel disease -Intractable seizures -Multiple sclerosis (MS) -Neurodegenerative diseases -Neuropathies -Opioid use disorder for which conventional therapeutic interventions are contraindicated or ineffective, or for which adjunctive therapy is indicated in combination with primary therapeutic interventions -Parkinson’s disease -Post-traumatic stress disorder (PTSD) -Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain -Sickle cell anemia -Terminal illness -Tourette syndrome

I understand

I understand that medical marijuana use for treatment of these conditions has not been approved by the Food and Drug Association ("FDA"). *

I understand

I have been advised and understand that the use of cannabis (medical marijuana) may affect my coordination and cognition in ways that could impair my ability to drive, operate heave machinery, or engage in potentially hazardous activities. *

I understand

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 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 toxins that normally present in marijuana smoke. *

I understand

Medical marijuana is available in many different forms and you are encouraged to speak with your provider about what they feel would be best for your diagnosis. You are advised that inhalation of medication is associated with lung pathology including lung cancer. Patients who are on home oxygen are also encouraged to use edible forms of medication to avoid the risk of burn injuries if medication is smoked. *

I understand

I understand that these side effects may occur while I am taking medical marijuana. These side effects have been explained to me. Side effects of medical marijuana can include, but are not limited to: *

-Headache -Decreased blood flow to the brain -Altered body temperature -Fatigue -Inattention -Aggressiveness -Sedation -Anxiety or panic -Inability to concentrate -Decreased verbal skills -Nystagmus- rapid & uncontrollable eye movement -Decreased coordination -Suicidal ideation -Increased food consumption and weight gain -Rapid heart rate -Reduced muscle strength -Altered libido/ Impotence -Hallucinations -Confusion -Paranoia -Euphoria -Amotivational syndrome -Increased talkativeness -Hunger -Addictive behaviors -Depersonalization -Reduced testicular size

I understand

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, disturbances to heart rhythms and numbness of the limbs and/or hacking cough. *

I understand

For some patients, chronic marijuana over use can lead to laryngitis, bronchitis, and general apathy. *

I understand

Using marijuana may decrease reproduction function in men as well as women. Women who are trying to conceive, or who are pregnant or breast-feeding should not use marijuana. Marijuana may increase risk of leukemia in children whose mothers smoked marijuana during pregnancy. Marijuana may also increase risk of an aggressive form of testicular cancer in men. *

I understand

I understand that some patients can become dependent on marijuana. This means they experience withdrawal symptoms when they stop using marijuana. Signs of withdrawal symptoms, while generally mild, can include feelings of depression, sadness or irritability, restlessness or mild agitation, insomnia, sleep disturbances, unusual tiredness, troubled concentration and/or loss of appetite. *

I understand

Although marijuana does not produce a specific psychosis, the possibility exists that it may exacerbate schizophrenia in persons predisposed to that disorder. *

I understand

I understand that using marijuana while under influence of alcohol is not recommended. *

I understand

I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and therefore may contain unknown quantities of active ingredients, impurities and/or contaminants. *

I understand

I agree to tell the attending physician/ nurse practitioner/ physician assistant/ medical provider if I have ever had symptoms of depression, been psychotic, attempted suicide, or had any other mental problem. I also agree to tell the attending physician if I have ever been prescribed or taken medicine for any of these problems. *

I understand

I understand that the attending physician/ nurse practitioner/ physician assistant/ medical provider does not suggest nor condone that I cease treatment of medications that stabilize my mental or physical condition. *

I understand

I affirm that I have a serious medical condition that adversely affects my quality of life. I have found or am interested in finding whether cannabis (medical marijuana) provides substantial relief and improvement in my condition. *

I understand

If I start taking medical marijuana, I agree to tell my attending physician/ nurse practitioner/ medical provider if I experience any adverse symptoms (side effects). *

I understand

I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and may contain unknown quantities of active ingredients, impurities and/ or contaminants. In requesting an approval or recommendation for the use of this plant as medication I assume full responsibility for any and all risks of this action. *

I understand

I am advised that the use of cannabis may affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and I or other individuals as a result of my use of cannabis. *

I understand

Some users develop a tolerance to marijuana. This means higher doses are required to achieve the same effect. If I think I may be developing a tolerance to marijuana, I will notify my attending physician. *

I understand

I agree to discontinue its use and report problems or side effects to the attending physician/ nurse practitioner/ medical provider. *

I understand

I understand that the attending physician/ nurse practitioner/ physician assistant/ medical provider, staff and representatives of this practice are neither providing nor dispensing cannabis, nor are they encouraging any illegal activity in my obtaining medical marijuana. *

I understand

I understand that the attending physician/ nurse practitioner/ physician assistant/ medical provider in order to conduct an appropriate evaluation, must do a physical exam and take my prior medical history and family history. *

I understand

At this time, cannabis is an alternative or complementary treatment. I understand to receive a recommendation for cannabis use, I should have tried, or be willing to consider trying, at least one other recommended treatment from a medical provider. I have obtained or attempted to obtain medical records pertaining to my condition or currently have to medical records pertaining my condition and agree to be referred for further evaluation as the physician deems necessary. *

I understand

I understand that should I be given a recommendation for medical use of cannabis, I understand that I must be regularly followed-up by a doctor and appear for a re-evaluation at a date specified by the attending physician/ nurse practitioner/ medical provider. *

I understand

I request a consultation by an attending physician/ nurse practitioner/ medical provider for the sole purposes of determining the appropriateness of medical cannabis treatment. I, the undersigned, understand that there are no representations about the medical efficacy of cannabis. *

I understand

I understand that the attending physician/ nurse practitioner/ medical provider , staff, and representatives at Psych Philly - Tracey Jones, M.D., P.C. are addressing specific aspects of my medical care, and, unless otherwise stated are in no way establishing themselves as my primary care provider. The attending physician/ nurse practitioner/ physician assistant/ medical provider is only rendering an opinion regarding the therapeutic indication of the use of medical marijuana. *

I understand

My heirs, assigns, or anyone acting on my behalf, hold the attending physician/ nurse practitioner/ medical provider and their principles, agents and employees, free of and harmless from any responsibility and liability resulting from the use of cannabis. In case any claim or dispute arises, I agree to arbitrate such claims/ disputes and I agree that Pennsylvania law will govern such claims/ disputes. *

I understand

Further, if any of these clauses is deemed invalid, the other clauses will remain in full effect. *

I understand

Digital Signature *

By typing my name below, I hereby grant the use of this information for the reasons explained in this form.

First Name

Last Name

Digital SIgnature - Guardian

Please utitilze this field if you are filling this out on behalf of somebody else. (Please place the patient's name in the field above.) By typing my name below, I hereby grant the use of this information for the reasons explained in this form.

First Name

Last Name

Today's Date *

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