What medical Conditions do you have?
Select all that apply, or write in if not listed:
List all of surgeries or hospitalizations:
Please list the TYPE OF REACTION:
(If you have your own list please just provide a copy)
I attest that the information on this form is correct and any medical history presented or discussed with the doctor is all factual and complete to the best of my knowledge. I do not plan or intend to use my Physician’s recommendation for the purpose of illegally obtaining medical marijuana. Solely for verification purposes, I authorize MMJ Care MD to converse of my medical condition. I understand that I must be a Florida State resident to obtain an approval or recommendation for the use of medical marijuana under the State of Florida Senate Bill SB 8-A (Medical Use of Marijuana) signed in to law by Governor Scott on June 23, 2017.
I affirm that I have a serious medical condition that negatively affects my quality of life. I have found or am interested in finding out whether or not medical marijuana provides substantial relief and improvement in my condition.
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 the potential risks associated with an elevated daily consumption of medical marijuana including risks with respect to the effect on my cardiovascular and pulmonary systems and psychomotor performance, risks associated with the long-term use of marijuana, as well as potential drug dependency. I am aware that the benefits and risks associated with the use of marijuana are not fully understood and that the use of marijuana may involve risks that have not been identified. In requesting an approval or recommendation for the use of medical marijuana, I assume full responsibility for any and all risks involved in this action.
I have been advised that medical marijuana smoke contains chemicals known as tars that may be harmful to my health. Recent research indicates that vaporizing cannabis may eliminate exposure to tar. Should respiratory problems or other ill effects be experienced in association with its use, it should be discontinued and reported to the physician immediately.
I was also advised that the use of medical marijuana 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/or other individuals as a result of my use of cannabis.
State of Florida Senate Bill SB 8-A (Medical Use of Marijuana), provides for the possession for the personal medical purposes of the patient with a physician approval or recommendation. It should be made clear that the physician, staff and representatives of this practice are not providing medical marijuana, nor are they encouraging any illegal activity in my obtaining medical marijuana.
I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal marijuana treatment. I acknowledge that using cannabis as a medicine has been explained to me and that any questions that I have asked to have been answered to my complete satisfaction. The physician, staff, and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider. Should an approval be made for my medicinal use of marijuana, I understand that there is a renewal date specified by the physician depending on the condition. I understand that it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval.
Furthermore, the undersigned, or anyone acting on my behalf, hold the physician and his/her principals, agents, and employees, free of and harmless from any liability resulting from the use of medical marijuana.
I further understand that by signing below, I am authorizing the release of any part of this record, except for identifying information, for use in data analysis of medical marijuana treated patients.
I hereby authorize the use/ access/ disclosure of my protected health information as describe below:
The following organization is authorized to make the disclosure:
(An abstract of the medical records consist of history and physical, discharge summary, consultations, operative reports, x-rays, labs,
EKG, Emergency room records and diagnostic studies).
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment of alcohol abuse.
This information is being provided to you from records whose confidentiality may be protected by State and/or Federal law.
I understand that, per Florida Statutes, I may be charged a fee of up to $1.00 per page (plus sales tax and postage) for every page copied. The fee is waived for copies provided to a health care provider for continuing medical care. I understand I have the right to inspect and obtain a copy of my protected health information in the designated record set you or your business associates maintain. I understand however I am not entitled to inspect or obtain a copy of any psychotherapy notes or any information compiled in anticipation of use of or for any civil, criminal or administrative action or proceeding, any information not subject to disclosure under the Clinical Laboratory Improvements Amendments of 1988, (42 U.S.C. section 263 (a), and certain other records.
I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I understand that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected under the terms of this authorization. I may inspect or copy any information used or disclosed under this authorization as described above. I understand that I may revoke this authorization in writing at any time. To understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released in response to this authorization.
This authorization expires within 90 days or upon (Date or Event).
A qualified physician may not delegate the responsibility of obtaining written informed consent to another person. The qualified patient, or the patient's parent or legal guardian if the patient is a minor, must initial each section of this consent form to indicate that the physician explained the information and, along with the qualified physician, must sign and date the informed consent form.
This consent form contains three parts. Part A must be completed by all patients. Part B is for patients under the age of 18, who have a terminal condition, when the medical marijuana is being ordered in a smokable form. Part C is the signature block and must be completed by all patients.
a. The Federal Government's classification of marijuana as a Schedule I controlled substance.
The federal government has classified marijuana as a Schedule I controlled substance. Schedule I substances are defined, in part, as having (I) a high potential for abuse; (2) no currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution and possession of marijuana even in states, such as Florida, which have modified their state laws to treat marijuana as a medicine.
When in the possession of medical marijuana, the patient or the patient's caregiver must have his or her medical marijuana use registry identification card in his or her possession at all times.
b. The approval and oversight status of marijuana by the Food and Drug Administration.
Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore, the "manufacture" of marijuana for medical use is not subject to any federal standards, quality control, or other federal oversight. Marijuana may contain unknown quantities of active ingredients, which may vary in potency, impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.
c. The potential for addiction
Some studies suggest that the use of marijuana by individuals may lead to a tolerance to, dependence on, or addiction to marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I should contact Dr.
d. The potential effect that marijuana may have on a patient's coordination, motor skills, and cognition, including a
warning against operating heavy machinery, operating a motor vehicle, or engaging in activities that require a
person to be alert or respond quickly.
The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. Driving under the influence of cannabis can double the risk of vehicular accident, which escalates if alcohol is also influencing the driver. While using medical marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly and I should not participate in activities that may be dangerous to myself or others. I understand that if I drive while under the influence of marijuana, I can be arrested for "driving under the influence."
e. The potential side effects of medical marijuana use.
Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory, euphoria, difficulty in completing complex tasks, suppression of the body's immune system, may affect the production of sex hormones that lead to adverse effects, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of medical marijuana may cause me to talk or eat in excess, alter my perception of time and space and impair my judgment. Many medical authorities claim that use of medical marijuana, especially by persons younger than 25, can result in long-term problems with attention, memory, learning, drug abuse, and schizophrenia.
There is substantial evidence of a statistical association between long-term cannabis smoking and worsening respiratory symptoms and more frequent chronic bronchitis episodes. Smoking marijuana is associated with large airway inflammation, increased airway resistance, and lung hyperinflation. Smoking cannabis, much like smoking tobacco, can introduce levels of volatile chemicals and tar in the lungs that may raise concerns about the risk of cancer and lung disease.
I understand that using marijuana while consuming alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.
I agree to contact Dr. if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact Dr. if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends.
f. The risks, benefits, and drug interactions of marijuana.
Signs of withdrawal can include: feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.
Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to contact Dr. immediately or go to the nearest emergency room.
Numerous drugs are known to interact with marijuana and not all drug interactions are known. Some mixtures of medications can lead to serious and even fatal consequences.I agree to follow the directions of Dr. regarding the use of prescription and nonprescription medication. I will advise any other of my treating physician(s) of my use of medical marijuana.
Marijuana may increase the risk of bleeding, low blood pressure, elevated blood sugar, liver enzymes, and other bodily systems when taken with herbs and supplements. I agree to contact Dr. immediately or go to the nearest emergency room if these symptoms occur.
I understand that medical marijuana may have serious risks and may cause low birthweight or other abnormalities in babies. I will advise Dr. if I become pregnant, try to get pregnant, or will be breastfeeding.
g. The current state of research on the efficacy of marijuana to treat the qualifying conditions set forth in this
There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for cancers, including glioma.
There is evidence to suggest that cannabinoids (and the endocannabinoid system more generally) may play a role in the cancer regulation processes. Due to a lack of recent, high quality reviews, a research gap exists concerning the effectiveness of cannabis or cannabinoids in treating cancer in general.
There is conclusive evidence that oral cannabinoids are effective antiemetics in the treatment of chemotherapyinduced nausea and vomiting.
There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for cancer-associated anorexia-cachexia syndrome and anorexia nervosa.
There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for epilepsy. Recent systematic reviews were unable to identify any randomized controlled trials evaluating the efficacy of cannabinoids for the treatment of epilepsy. Currently available clinical data therefore consist solely of uncontrolled case series, which do not provide high-quality evidence of efficacy. Randomized trials of the efficacy of cannabidiol for different forms of epilepsy have been completed and await publication.
There is limited evidence that cannabinoids are an ineffective treatment for improving intraocular pressure associated with glaucoma.
Lower intraocular pressure is a key target for glaucoma treatments. Nonrandomized studies in healthy volunteers and glaucoma patients have shown short-term reductions in intraocular pressure with oral, topical eye drops, and intravenous cannabinoids, suggesting the potential for therapeutic benefit. A good-quality systemic review identified a single small trial that found no effect of two cannabinoids, given as an oromucosal spray, on intraocular pressure. The quality of evidence for the finding of no effect is limited. However, to be effective, treatments targeting lower intraocular pressure must provide continual rather than transient reductions in intraocular pressure. To date, those studies showing positive effects have shown only short-term benefit on intraocular pressure (hours), suggesting a limited potential for cannabinoids in the treatment of glaucoma.
Positive status for human immunodeficiency virus
There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite and decreasing weight loss associated with HIV/AIDS.
There does not appear to be good-quality primary literature that reported on cannabis or cannabinoids as effective treatments for AIDS wasting syndrome.
Acquired immune deficiency syndrome
Post-traumatic stress disorder
There is limited evidence (a single, small fair-quality trial) that nabilone is effective for improving symptoms of posttraumatic stress disorder
A single, small crossover trial suggests potential benefit from the pharmaceutical cannabinoid nabilone. This limited evidence is most applicable to male veterans and contrasts with nonrandomized studies showing limited evidence of a statistical association between cannabis use (plant derived forms) and increased severity of posttraumatic stress disorder symptoms among individuals with posttraumatic stress disorder. There are other trials that are in the process of being conducted and if successfully completed, they will add substantially to the knowledge base.
Amyotrophic lateral sclerosis
There is insufficient evidence that cannabinoids are an effective treatment for symptoms associated with amyotrophic lateral sclerosis. Two small studies investigated the effect of dronabinol on symptoms associated with ALS. Although there were no differences from placebo in either trial, the sample sizes were small, the duration of the studies was short, and the dose of dronabinol may have been too small to ascertain any activity. The effect of cannabis was not investigated.
There is insufficient evidence to support or refute the conclusion that dronabinol is an effective treatment for the symptoms of irritable bowel syndrome.
Some studies suggest that marijuana in the form of cannabidiol may be beneficial in the treatment of inflammatory bowel diseases, including Crohn's disease.
There is insufficient evidence that cannabinoids are an effective treatment for the motor system symptoms associated with Parkinson's disease or the levodopainduced dyskinesia.
Evidence suggests that the endocannabinoid system plays a meaningful role in certain neurodegenerative processes; thus, it may be useful to determine the efficacy of cannabinoids in treating the symptoms of neurodegenerative diseases. Small trials of oral cannabinoid preparations have demonstrated no benefit compared to a placebo in ameliorating the side effects of Parkinson's disease. A seven-patient trial of nabilone suggested that it improved the dyskinesia associated with levodopa therapy, but the sample size limits the interpretation of the data. An observational study demonstrated improved outcomes, but the lack of a control group and the small sample size are limitations.
There is substantial evidence that oral cannabinoids are an effective treatment for improving patient-reported multiple sclerosis spasticity symptoms, but limited evidence for an effect on clinician-measured spasticity. Based on evidence from randomized controlled trials included in systematic reviews, an oral cannabis extract, nabiximols, and orally administered THC are probably effective for reducing patient-reported spasticity scores in patients with MS. The effect appears to be modest. These agents have not consistently demonstrated a benefit on clinician-measured spasticity indices.
Medical conditions of same kind or class as or comparable to the above qualifying medical conditions
The qualifying physician has provided the patient or the patient's parent or legal guardian a summary of the current research on the efficacy of marijuana to treat the patient's medical condition.
The summary is attached to this informed consent as Addendum .
Terminal conditions diagnosed by a physician other than the qualified physician issuing the physician certification
Chronic nonmalignant pain
There is substantial evidence that cannabis is an effective treatment for chronic pain in adults.
The majority of studies on pain evaluated nabiximols outside the United States. Only a handful of studies have evaluated the use of cannabis in the United States. and all of them evaluated cannabis in flower form provided by the National Institute on Drug Abuse. In contrast, many of the cannabis products that are sold in state-regulated markets bear little resemblance to the products that are available for research at the federal level in the United States. Pain patients also use topical forms.
While the use of cannabis for the treatment of pain is supported by well controlled clinical trials, very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.
h. That the patient's de-identified health information contained in the physician certification and medical marijuana use registry may be used for research purposes.
The Department of Health submits a data set to the Consortium for Medical Marijuana Clinical Outcomes Research for each patient registered in the medical marijuana use registry that includes the patient's qualifying medical condition and the daily dose amount and forms of marijuana certified for the patient.
Initial here if you are not a terminal patient under 18 who will be receiving medical marijuana in a smokable form. After initialing here, complete part C.
If the patient is under 18, has a terminal condition, and will be receiving medical marijuana in a smokable form, please review and initial the remainder of Part B before completing Part C.
Exposures to tobacco smoke and household air pollution consistently ranks among the top risk factors not only for respiratory disease burden but also for the global burden of disease. Given the known relationships between tobacco smoking and multiple respiratory conditions, one could hypothesize that long-term cannabis smoking leads to similar deleterious effects of respiratory health, and some investigators argue that cannabis smoking may be even more harmful that of tobacco smoking. Data collected from 15 volunteers suggest that smoking one cannabis joint can lead to four times the exposure to carbon monoxide and three to five times more tar deposition than smoking a single cigarette.
Cognitive and Psychosocial Development
Researchers are still studying the long-term health effects of marijuana. Most people agree that marijuana use hurts adolescents more than adults. It is during the period of adolescence and young adulthood that the neural substrates that underlie the development of cognition are most active. Adolescence marks one of the most impressive stretches of neural and behavioral change with substantial a protracted development in terms of both brain structure and function. As a result, cannabis and other substance use during this period may incur relatively greater interference in neural, social, and academic functioning compared to late developmental periods.
There is moderate evidence of a statistical association between acute cannabis use and impairment in the cognitive domains of learning, memory, and attention.
There is limited evidence of a statistical association between sustain abstinence form cannabis use and impairments in the cognitive domains of learning, memory, and attention.
There is limited evidence of a statistical association between cannabis use and impaired academic achievement and education outcomes.
There is limited evidence of a statistical association between cannabis use and increased rates of unemployment and/or low income.
There is limited evidence of a statistical association between cannabis use and impaired social functioning or engagement in developmentally appropriate social roles.
Marijuana, like some other brain-altering substances, can be addictive. Nearly one in 10 marijuana users will become addicted. Starting to use marijuana at a younger age can lead to a greater risk of developing a substance use disorder later in life. Adolescents who begin using marijuana before age 18 are four to seven times more likely than adults to develop a marijuana use disorder
I have had the opportunity to discuss these matters with the physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge that Dr. has informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana.
Dr. also informed me of the risks, complications, and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that Dr. informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits. Dr. has explained the information in this consent form about the medical use of marijuana. Patient (print name) Patient signature or signature of the parent or legal guardian if the patient is a minor: Date I have explained the information in this consent form about the medical use of marijuana to (Print patient name). Qualified physician signature: Date Witness: Date
First visit and recommendations $250.00. Payment plan is available if you are unable to make a payment in full.
Services included with your fee:
3 70-day recommendations, for a total of 210 days of coverage
Assistance in the completion of your initial patient application to the DoH
Adjustments made to recommendations as per patient request and doctor approval
Professional services and timely responses to all formal inquires
Follow up visits $150.00. Payment plan is available if you are unable to make a payment in full.
Upon request, assistance in the completion of your annual renewal application to the DoH
We do not accept any type of insurance.
All forms of payment, including credit cards, are accepted.
State of Florida requires a separate application fee of $75.00 that must be paid to State of Florida before your MMJ license is issued. This an ANNUAL fee that must be paid to keep your MMJ license active. Patients are required to monitor the date of their license’s expiration, and assistance with the renewal is available upon request. All online transactions to the State of Florida carry a $2.75 processing fee.
Dispensaries will be located near you and a list of local dispensaries can be provided for you. If you are unable to visit a dispensary, delivery service from any dispensary to your residence is available for free or a nominal charge.