Medical Cannabis Certification Consent & Patient Agreement

# Medical Cannabis Certification Consent & Patient Agreement **Practice / Certifying Physician:** ___________ **Physician Name:** ___________, ___________, license number ___________, State of ___________, NPI ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **State Program:** ___________ Medical Cannabis Program **Date of Consent:** ___________ --- ## 1. Qualifying Condition The physician has determined that the Patient has been diagnosed with the following condition(s) qualifying under ___________ law: ___________. The recommendation for medical cannabis is based on the physician's clinical evaluation of the Patient's condition, treatment history, and the available clinical evidence that cannabis may provide symptom relief for the Patient's qualifying condition. --- ## 2. Nature of the Physician Certification A physician medical cannabis certification (or "recommendation") is an attestation that the Patient has a qualifying medical condition under state law. It is **not** a prescription in the conventional pharmaceutical sense. Cannabis is not FDA-approved as a drug product (with the exception of specific cannabinoid-derived medications such as Epidiolex® for seizure disorders). The Patient understands that: - The certifying physician is not prescribing a specific pharmaceutical product. - Cannabis products vary substantially in composition, potency, and quality. - The Patient purchases cannabis products from a licensed state dispensary, not a pharmacy. - The certifying physician does not endorse or guarantee the safety or efficacy of any specific product. --- ## 3. Federal Law Notice **Cannabis remains a Schedule I controlled substance under the federal Controlled Substances Act (21 U.S.C. § 812).** State medical cannabis laws do not supersede federal law. The Patient acknowledges: - Possession or use of cannabis may result in federal criminal penalties in federal jurisdictions (federal lands, federal buildings, airports, federal prisons, military bases, Veterans Affairs facilities).