Marijuana User for Medical Purposes
Documentation of Discussion with Patient
Patient's Name________________________ Date of Birth ________________
Address _____________________________
City/State ____________________________ Zip Code ___________________
Social Security Number _________________ Phone _____________________
| This is to certify that _______________________ is a patient of mine at the
Santa Cruz County General Medical Clinic and is under my care for the treatment of:
_____________________________________________________________ From a purely medical perspective, I deem the use of marijuana may be appropriate in the treatment of your condition (s) and recommend, approve, endorse suggest or advise (circle one) such use for the treatment of your condition. This is not a prescription but merely a statement of my professional opinion that use of marijuana could be medically beneficial in your case. This letter documents that we have discussed that marijuana is considered a Schedule I drug by the federal government and that, under federal law, possession, use, cultivation, and sale of marijuana is illegal. We have further discussed that medical necessity does not provide a defense to violation of federal law. In no way do I intend, through this discussion, to encourage your engaging in illegal activity. I am merely providing my opinion, based upon my understanding of the currently available medical and scientific evidence, of the potential efficacy of marijuana for the treatment of symptoms associated with your condition (s). If you do choose to use marijuana, I will expect you to keep appointments so that I am able to monitor your condition. |
Physician’s Name ________________________CA License No. ___________
Physician’s Address ______________________
Physician’s Phone _______________________
Physician’s Signature ____________________ Date _____________________
Patient’s Signature ______________________ Date _____________________
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