Medical Marijuana Physician Certification Form - Arizona

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M E D I C A L M A R I J U A N A P HY S IC I A N C E R T I F I C A T I O N

P H Y S I C I A N I N F O R M A T I O N

F O R A L L Q U A L I F Y I N G P A T I E N T S

Physician’s Name:

Arizona License Number:

Type:

NMD/ND

MD(H)/DO(H)

P H Y S I C I A N I N F O R M A T I O N O N F I L E W I T H L I C E N S I N G B O A R D

Office Address:

Telephone Number:

Email Address:

Q U A L I F Y I N G P A T I E N T I N F O R M A T I O N

Patient’s Name:

Date of Birth:

’

CHECK ONE OR MORE BOXES TO INDICATE QUALIFYING PATIENT

S DEBILITATING MEDICAL CONDITION

Acquired immune deficiency syndrome (AIDS)

Agitation of Alzheimer's disease

Amyotrophic lateral sclerosis (ALS)

Cancer

Crohn's disease

Glaucoma

Human immunodeficiency virus (HIV)

Hepatitis C

IF A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION OR THE TREATMENT FOR A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION CAUSES

Cachexia or wasting syndrome

Severe and chronic pain

Severe nausea

Seizures, including those characteristic of epilepsy

Severe or persistent muscle spasms, including those characteristic of multiple sclerosis

IF ANY CONDITION ABOVE IS CHECKED

INDICATE THE UNDERLYING CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION

I, ________________________________________,

THE PHYSICIAN

•

Have made or confirmed a diagnosis of a debilitating medical condition, as defined in

A.R.S. §

36-2801, for the qualifying patient.

YES

Initial: __________

•

Have established a medical record for the qualifying patient and am maintaining the qualifying patient's medical record as required in

A.R.S. §

12-2297.

YES

Initial: __________

•

Have conducted an in-person physical examination of the qualifying patient within the last 90 calendar days appropriate to the qualifying patient's presenting

symptoms and the debilitating medical condition I diagnosed or confirmed.

YES

Date of Examination: ________________________ Initial: __________

•

Have reviewed the qualifying patient's medical records, including medical records from other treating physicians from the previous 12 months, the qualifying

patient’s responses to conventional medications and medical therapies, and the qualifying patient’s profile on the Arizona Board of Pharmacy Controlled

Substances Prescription Monitoring Program database.

YES

Initial: __________

•

Have explained the potential risks and benefits of the medical use of marijuana to the qualifying patient or, if applicable, the qualifying patient’s custodial

parent or legal guardian.

YES

Initial: __________

•

Have referred the qualifying patient to a dispensary. YES

If YES, I have disclosed to the qualifying patient or, if applicable, the qualifying

patient’s custodial parent or legal guardian any personal or professional relationship I have with the dispensary.

YES

Initial: __________

’

P H Y S I C I A N

S A T T E S T A T I O N

I, ________________________________________, in my professional opinion believe that the qualifying patient is likely to receive therapeutic or palliative benefit

from the qualifying patient’s medical use of marijuana to treat or alleviate the qualifying patient’s debilitating medical condition. I attest that the information provided

in this written certification is true and correct.

_______________________________________________

_________________________

Physician’s Signature

Date Signed