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Medical Marijuana Program Documentation of Patient's Medical Records (California) Mobile App

If the Medical Marijuana Program Documentation of Patient's Medical Records (California) mobile app is used, this form will serve as written documentation from the attending physician, stating that the patient has been diagnosed with a serious medical condition and that the medical use of marijuana is appropriate. A copy of this form must be filed in the attending physician’s medical records for the patient. If the patient chooses to apply for a Medical Marijuana Identification card through the county health department or its designee, the agency will call the attending physician to verify the information contained on this form, in accordance with Health & Safety Code, Section11362.72 (a)(3). Use canvas to populate a Value List ( Drop-Down).

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Take a peek inside the Medical Marijuana Program Documentation of Patient's Medical Records (California) Mobile App

Included Features

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Included Fields

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    WRITTEN DOCUMENTATION OF PATIENT’S MEDICAL RECORDS

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    Note to Attending Physician: This is not a mandatory form.

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    Attending physician name

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    California medical license number

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    Service mailing address (number, street)

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    City

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    State

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    ZIP code

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    Office fax

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    Office telephone number

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    Licensed by (check one):

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    Medical Board of California

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    Osteopathic Medical Board of California

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    Patient’s name

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    is a patient under the medical care and supervision of the above named physician who has diagnos...

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    1. Acquired Immune Deficiency Syndrome (AIDS)

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    2. Anorexia

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    3. Arthritis

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    4. Cachexia

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    5. Cancer

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    6. Chronic pain

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    7. Glaucoma

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    8. Migraine

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    9. Persistent muscle spasms, including, but not limited to, spasms associated with multiple scler...

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    10. Seizures, including, but not limited to, seizures associated with epilepsy

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    11. Severe nausea

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    12. Any other chronic or persistent medical symptom that either:

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    a.

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