The Washington State Medical Marijuana Authorization Agency LLC

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Patient Intake Form

Name:
Date of Birth:
Adress:
Phone Number:
City:
State:
Zip Code:
Primary Phone:
Secondary Phone:
E-mail:
Other conditions you may recall?
Medical History: Indicate any conditions you have experienced or are currently experiencing: Please note: not all conditions represent a qualifying condition, as stated in the Medical Marijuana Act. This is general health information for our health care professionals to better serve you in an event you may have a medical emergency.
Current Medical Status
Dosage:
Frequency:
Allergies:
Primary Care Physician Doctors Name:
Clinic Name:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Current Problems Please list any problems you are currently experiencing:
Recent Injuries and/or Surgeries Have you recently had any surgeries? If so, where and when?
Have you sustained any bodily injuries? Yes/No When did this occur?
Emergency Contact Information Name of emergency contact:
Relationship:
Phone:
Email:
City/State
Zip Code:
Relationship:
Last Physical Exam:
I certify that the above information is correct. I understand my information is protected by Federal and State Laws and will not be disclosed to anyone outside of The Washington State Medical Marijuana Authorization Agency, LLC without my written consent. Please electronically give your signature by entering your full name here:
Date:

Medical Marijuana Acknowledgment of Disclosure and Informed Consent

Please read below and electronically sign to indicate that you understand and agree you have been advised of the health risks of Marijuana. By signing, you understand and agree to the information. If you have questions or do not understand the information below, consult with the attending physician before initialing or signing this agreement. Please do not sign this agreement and do not use medical marijuana if you do not understand the following information you have received. I, ______________________________, understand that medical marijuana is a medicine used in treating the suffering caused by serious and debilitating medical conditions. Serious and debilitating medical conditions include cancer, HIV, nausea, arthritis, chronic pain, glaucoma, cachexia, migraine headaches, anorexia, seizures, and persistent muscle spasms. Additionally, medical marijuana is used in the treatment of other chronic or persistent symptoms that: Substantially limits the ability of the person to conduct one or more major life activities as define in the American with Disabilities Act of 1990 (Public Law 101-336) Other conditions for which marijuana provides relief; If not alleviated, may cause harm to the patient’s safety or physical or mental health. I am aware that I am paying for a medical examination and evaluation with the physician. The fee for the evaluation does not guarantee that I will receive a recommendation. If I do not qualify for a recommendation a refund will not be issued. I have been advised that the use of cannabis (medical marijuana) may affect my coordination and cognition in ways that could impaired my ability to drive a vehicle and agree not to operate heavy machinery, drive or engage in potentially hazardous activities. I understand the side effects may occur while I am taking medical marijuana. Side effects of medical marijuana can include but are not limited to: increased heart rate, euphoria, dysphoria, confusion, low blood pressure, dizziness, inability to concentrate, sedation, anxiety, paranoia, delusion, suppression of the body’s immune system, impairment of shorter term memory, alterations in the perception of time and space, difficulty in completing complex tasks, impairment of motor skills, reaction time and physical coordination. I understand that some patients can become dependent on marijuana. This mean they experience mild withdrawal symptoms when they stop using marijuana, Signs of withdrawal symptoms, while generally mild can include: feelings of depression, sadness and irritability, restlessness or mild agitation, insomnia, loss of appetite, sleep disturbance, trouble concentrating, and unusual tiredness. For some patients, chronic marijuana use can lead to laryngitis, bronchitis and general apathy. Although marijuana does not produce specific psychosis, the possibility exists that may exacerbate schizophrenia on persons predisposed to that disorder. I am here under my own freewill, am of sound mind and have been informed of the risks associated with the use of medical marijuana. I hereby certify that the information I provide is true and correct to the best of my knowledge. I hold harmless The Washington State Medical Marijuana Authorization Agency, and any other entity that I have provided false information to
Please enter your name here to electronically give your signature stating you have been advised of the health risks associated with Marijuana:

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