New Patient Intake Form
Please fill out the form prior to your evaluation
Patients Obtaining Their Medical Card For The First Time: Must Enter Their Valid Florida's Driver License and or Id Card an SSN.* Required by the State
Please make sure you can get into your email inbox you will need to in order to register on the state site at your evaluation.
Release of Liability
I attest that the information in this form is correct and any medical history presented or discussed with the doctor is 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 MD Marijuana Card Express to converse of my medical condition.
I understand that I must be a Florida State resident to obtain an approval or recommendation for the use of Low- THC cannabis or medical cannabis under the Compassionate Medical Cannabis Act of 2014.
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 improvement in my condition.
I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and therefore may contain unknown quantities of active ingredients, impurities, and/ or contaminants. I understand the potential risk associated with an elevated daily consumption of medical marijuana including risks with respect to the effect on my cardiovascular and pulmonary systems and psychomotor performance, risks associated with the long term use of marijuana, as well as potential drug dependency. I am aware that the benefits and risks associated with the use of marijuana are not fully understood and that the use of marijuana may involve risks that have not been identified. In requesting an approval or recommendation for the use of medical marijuana, I assume full responsibility for any and all risks involved in this action.
I have been advised that medical marijuana smoke contains chemicals known as tars that may be harmful to my health. Recent research indicates that vaporizing cannabis may eliminate exposure to tar. Should respiratory problems or other ill effects be experienced in association with its use, it should be discontinued and reported to the physician immediately.
I was also advised that the use of medical marijuana may affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my use of cannabis. The Florida Office of Compassionate Use (HB 307 effective March 2, 2016) provides for the possession of the personal medical purposes of the patient with a physician approval or certification. It should be made clear that the physician staff and representatives of this practice are neither providing medical marijuana, nor are they encouraging any illegal activity in obtaining medical marijuana.
I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medical 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 medicinal use of marijuana, I understand that there is a renewal date specified by the physician depending on the condition. I understand it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of approval.
“Under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against non-insured physicians who fail to satisfy adverse judgements arising from claims of medical malpractice. This notice is provided pursuant to Florida law.”
Furthermore, the undersigned, or anyone acting on my behalf, holds the physician and his/her principals, agens 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.
Medical Marijuana Patient Declaration
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 purposes 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 HIPPA 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. I also hereby authorize MD Marijuana Card Express, or its representative to discuss my medical condition for verification purposes only.
Additionally, I acknowledge the attending physician informed me of the nature of a recommendation of 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 acknowledge the attending physician informed me of alternatives to the recommended treatment, including the alternative of no treatment and their risks and benefits. The physician may request that I visit another physician or specialist to further substantiate my condition. I will be informed of all the above mentioned regardless of whether or not I qualify as a patient.
HIPAA Notice of Privacy Practices Acknowledgment of Receipt
By initialing this, I hereby acknowledge that I have read and understand the privacy practice notice and may obtain additional copies upon my request. This acknowledgment will be filed with my records.
Authorization for Release of Confidential Records
I hereby Authorize MD Marijuana Card Express to disclose and verify me as a patient to any law enforcement agency, my physicians, Child Protective Services or any state approved Florida dispensary. This is valid during the period of time for which the recommendation has been issued. The consent is subject to written revocation only, at any time except to the extent that action has already been taken on the basis of this consent.
I give permission for my medical records and file to be reviewed by another physician working with MD Marijuana Card Express. I understand that this might happen if the original doctor who evaluated me needs a secondary opinion , is not available, off premise, has moved or terminated his/her practice.
I have asked the patient if he/she has any questions regarding his/her treatment with medical marijuana. I have answered those questions to the best of my ability.