Patient *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patients Phone *

(###)

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Primary Physician Phone

(###)

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Emergency Contact Phone

(###)

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If Female, Check Box If You Are Currently Pregnant or Think That You May Be

Check Box If You Are Planning on Getting Pregnant

Check Box If You Are Currently Breast-Feeding

Do you drink coffee?

Yes

No

Do you drink alcohol?

Yes

No

Do you drink Tea?

Yes

No

Do you use Tabacco?

Yes

No

Check Box If You Currently Use Marijuana

Yes

No

I attest that the information on this form is correct and any medical history presented or discussed with the doctor is all factual and complete to the best of my knowledge. I do not plan or intend to use my Physician’s recommendation for the purpose of illegally obtaining medical marijuana. Solely for verification purposes, I authorize Lotus Health LLC to converse of my medical condition.

I understand that I must be an Ohio resident to obtain an approval or recommendation for the use of medical cannabis.
I affirm that I have a serious medical condition that negatively affects my quality of life. I have found or am interested in finding out whether or not medical marijuana provides substantial relief and improvements to my condition.
I agree to tell the attending physician if I ever have symptoms of depression, been psychotic, attempted suicide or had any other mental problems. I also agree to tell the attending physician if I have ever been prescribed or taken medicine for any of the conditions stated above. Furthermore, I understand that the attending physician does not suggest nor condone that I cease treatment and/or medication that stabilize my mental or physical condition.
I am aware that a Notice of Compliance has not been issued under the Food and Drug Regulations concerning the safety and effectiveness of marijuana as a drug. I understand the significance of this fact.
I am aware that medical marijuana has not been approved under Federal Regulations and I understand that medical marijuana has not been deemed legal under federal law. Although smoking marijuana has not been linked to lung cancer, smoking marijuana can cause respiratory harm, such as bronchitis. Many researchers agree that marijuana smoke contains known carcinogens (chemicals that can cause cancer) and that smoking marijuana may increase the risk of respiratory diseases and cancers in the lungs, mouth and tongue. I have been advised that medical marijuana smoke contains chemicals known as tars that may be harmful to my health.
I understand that there are many methods of intake that substantially reduce the harmful effects of smoking such as edibles, tinctures, etc.
I agree that if I am a female patient that I will contact my attending physician if I become or are thinking about becoming pregnant.
I understand that I should not be driving a vehicle while using marijuana and that I can get a DUI for driving under the influence.I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition and attest that I do not intend to use my medical recommendation for the purpose of illegally obtaining, growing or distributing medical marijuana.
I attest that I am not a member, employee or agent of any media or law enforcement agency. It is illegal to film or record in this office with a video camera, cell phone, or any other recording device be it a still image, video or audio. This is a direct violation of HIPAA regulations and patient/doctor confidentiality.
I am aware that my recommendation can be revoked at any time and legal actions will be taken if I have perjured or misrepresented myself or my condition, my intentions or falsified any medical records to the physician. Additionally, I acknowledge the attending physician informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana. The risks, complications and expected benefits of any recommended treatment, including its likelihood of success or failure.

I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal marijuana treatment.
I acknowledge that using cannabis as a medicine has been explained to me and that any questions that I have asked have been answered to my complete satisfaction. The physician, staff, and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider. Should an approval be made for my medical use of marijuana, I understand that there is a renewal date specified by the physician depending on the condition.
I understand that it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval.
Furthermore, the undersigned, or anyone acting on my behalf, hold the physician and his/her principals, agents, and employees, free of and harmless from any liability resulting from the use of medical marijuana.

I further understand that by signing below, I am authorizing the release of any part of this record, except for identifying information, for use in data analysis of medical marijuana treated patients. *

First Name

Last Name

I have Read and Agree. I understand that submitting my information acts as my signature *

Today's Date *

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