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Medical Marijuana Consent Form

A qualified physician may not delegate the responsibility of obtaining written informed consent to
another person. The qualified patient, or the patient's parent or legal guardian if the patient is a minor,
must initial each section of this consent form to indicate that the physician explained the information
and, along with the qualified physician, must sign and date the informed consent form.
This consent form contains three parts. Part A must be completed by all patients. Part B is only required
for patients under the age of 18 with a diagnosed terminal condition who receive a certification for
medical marijuana in a smokable form. Part C is the signature block and must be completed by all
patients.
Part A: Must be completed for all medical marijuana patients
a. The Federal Government's classification of marijuana as a Schedule I controlled substance.
The federal government has classified marijuana as a Schedule I controlled substance. Schedule I
substances are defined, in part, as having (I) a high potential for abuse; (2) no currently accepted
medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical
supervision. Federal law prohibits the manufacture, distribution and possession of marijuana even
in states, such as Florida, which have modified their state laws to treat marijuana as a medicine.
When in the possession of medical marijuana, the patient or the patient's caregiver must have his or
her medical marijuana use registry identification card in his or her possession at all times.
b. The approval and oversight status of marijuana by the Food and Drug Administration.
Marijuana has not been approved by the Food and Drug Administration for marketing as a drug.
Therefore, the "manufacture" of marijuana for medical use is not subject to any federal standards,
quality control, or other federal oversight. Marijuana may contain unknown quantities of active
ingredients, which may vary in potency, impurities, contaminants, and substances in addition to THC,
which is the primary psychoactive chemical component of marijuana.
c. The potential for addiction.
Some studies suggest that the use of marijuana by individuals may lead to a tolerance to,
dependence on, or addiction to marijuana. I understand that if I require increasingly higher doses
to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I
should contact Dr. (name of qualified physician).

d. The potential effect that marijuana may have on a patient's coordination, motor skills, and
cognition, including a warning against operating heavy machinery, operating a motor vehicle, or
engaging in activities that require a person to be alert or respond quickly.
The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge
and reason. Driving under the influence of cannabis can double the risk of vehicular accident, which
escalates if alcohol is also influencing the driver. While using medical marijuana, I should not drive,
operate heavy machinery or engage in any activities that require me to be alert and/or respond
quickly and I should not participate in activities that may be dangerous to myself or others. I

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understand that if I drive while under the influence of marijuana, I can be arrested for "driving under
the influence."
e. The potential side effects of medical marijuana use.
Potential side effects from the use of marijuana include, but are not limited to, the following:
dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory,
euphoria, difficulty in completing complex tasks, suppression of the body's immune system, may
affect the production of sex hormones that lead to adverse effects, inability to concentrate,
impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or
restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In
addition, the use of medical marijuana may cause me to talk or eat in excess, alter my perception
of time and space and impair my judgment. Many medical authorities claim that use of medical
marijuana, especially by persons younger than 25, can result in long-term problems with attention,
memory, learning, drug abuse, and schizophrenia.
There is substantial evidence of a statistical association between long-term cannabis smoking and
worsening respiratory symptoms and more frequent chronic bronchitis episodes. Smoking
marijuana is associated with large airway inflammation, increased airway resistance, and lung
hyperinflation. Smoking cannabis, much like smoking tobacco, can introduce levels of volatile
chemicals and tar in the lungs that may raise concerns about the risk of cancer and lung disease.
I understand that using marijuana while consuming alcohol is not recommended. Additional side
effects may become present when using both alcohol and marijuana.
I agree to contact Dr. if I experience any of the side effects listed above, or
if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also
contact Dr. if I experience respiratory problems, changes in my normal sleeping
patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or
friends.

f. The risks, benefits, and drug interactions of marijuana.
Signs of withdrawal can include: feelings of depression, sadness, irritability, insomnia,
restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual
tiredness.
Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking
cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety
attacks and incapacitation. If I experience these symptoms, I agree to contact Dr.

immediately or go to the nearest emergency room.

Numerous drugs are known to interact with marijuana and not all drug interactions are known.
Some mixtures of medications can lead to serious and even fatal consequences.

I agree to follow the directions of Dr. regarding the use of prescription and non-
prescription medication. I will advise any other of my treating physician(s) of my use of medical

marijuana.

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Marijuana may increase the risk of bleeding, low blood pressure, elevated blood sugar, liver
enzymes, and other bodily systems when taken with herbs and supplements. I agree to contact
Dr. immediately or go to the nearest emergency room if these symptoms
occur.
I understand that medical marijuana may have serious risks and may cause low birthweight
or other abnormalities in babies. I will advise Dr. if I become pregnant,
try to get pregnant, or will be breastfeeding.

g. The current state of research on the efficacy of marijuana to treat the qualifying conditions set
forth in this section.
Cancer
• There is insufficient evidence to support or refute the conclusion that cannabinoids are an effective
treatment for cancers, including glioma.
There is evidence to suggest that cannabinoids (and the endocannabinoid system more
generally) may play a role in the cancer regulation processes. Due to a lack of recent, high quality
reviews, a research gap exists concerning the effectiveness of cannabis or cannabinoids in
treating cancer in general.
• There is conclusive evidence that oral cannabinoids are effective antiemetics in the treatment of
chemotherapy-induced nausea and vomiting.
There is insufficient evidence to support or refute the conclusion that cannabinoids are an
effective treatment for cancer-associated anorexia-cachexia syndrome and anorexia nervosa.
Epilepsy
• There is insufficient evidence to support or refute the conclusion that cannabinoids are an
effective treatment for epilepsy.
Recent systematic reviews were unable to identify any randomized controlled trials evaluating
the efficacy of cannabinoids for the treatment of epilepsy. Currently available clinical data
therefore consist solely of uncontrolled case series, which do not provide high-quality evidence
of efficacy. Randomized trials of the efficacy of cannabidiol for different forms of epilepsy have
been completed and await publication.
Glaucoma
• There is limited evidence that cannabinoids are an ineffective treatment for improving intraocular
pressure associated with glaucoma.
Lower intraocular pressure is a key target for glaucoma treatments. Nonrandomized studies in
healthy volunteers and glaucoma patients have shown short-term reductions in intraocular
pressure with oral, topical eye drops, and intravenous cannabinoids, suggesting the potential for
therapeutic benefit. A good-quality systemic review identified a single small trial that found no
effect of two cannabinoids, given as an oromucosal spray, on intraocular pressure. The quality
of evidence for the finding of no effect is limited. However, to be effective, treatments targeting
lower intraocular pressure must provide continual rather than transient reductions in intraocular

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pressure. To date, those studies showing positive effects have shown only short-term benefit on
intraocular pressure (hours), suggesting a limited potential for cannabinoids in the treatment of
glaucoma.
Positive status for human immunodeficiency virus
• There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite
and decreasing weight loss associated with HIV/AIDS.
There does not appear to be good-quality primary literature that reported on cannabis or
cannabinoids as effective treatments for AIDS wasting syndrome.
Acquired immune deficiency syndrome
• There is limited evidence that cannabis and oral cannabinoids are effective in increasing appetite
and decreasing weight loss associated with HIV/AIDS.
There does not appear to be good-quality primary literature that reported on cannabis or
cannabinoids as effective treatments for AIDS wasting syndrome.

____ Post-traumatic stress disorder
• There is limited evidence (a single, small fair-quality trial) that nabilone is effective for improving
symptoms of posttraumatic stress disorder
A single, small crossover trial suggests potential benefit from the pharmaceutical cannabinoid

nabilone. This limited evidence is most applicable to male veterans and contrasts with non-
randomized studies showing limited evidence of a statistical association between cannabis use

(plant derived forms) and increased severity of posttraumatic stress disorder symptoms among
individuals with posttraumatic stress disorder. There are other trials that are in the process of
being conducted and if successfully completed, they will add substantially to the knowledge
base.
Amyotrophic lateral sclerosis
• There is insufficient evidence that cannabinoids are an effective treatment for symptoms associated
with amyotrophic lateral sclerosis.
Two small studies investigated the effect of dronabinol on symptoms associated with ALS.
Although there were no differences from placebo in either trial, the sample sizes were small,
the duration of the studies was short, and the dose of dronabinol may have been too small to
ascertain any activity. The effect of cannabis was not investigated.

____ Crohn's disease
• There is insufficient evidence to support or refute the conclusion that dronabinol is an effective
treatment for the symptoms of irritable bowel syndrome.
Some studies suggest that marijuana in the form of cannabidiol may be beneficial in the
treatment of inflammatory bowel diseases, including Crohn's disease.

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____ Parkinson's disease
• There is insufficient evidence that cannabinoids are an effective treatment for the motor system
symptoms associated with Parkinson's disease or the levodopa induced dyskinesia.
Evidence suggests that the endocannabinoid system plays a meaningful role in certain
neurodegenerative processes; thus, it may be useful to determine the efficacy of cannabinoids
in treating the symptoms of neurodegenerative diseases. Small trials of oral cannabinoid
preparations have demonstrated no benefit compared to a placebo in ameliorating the side
effects of Parkinson's disease. A seven-patient trial of nabilone suggested that it improved the
dyskinesia associated with levodopa therapy, but the sample size limits the interpretation of
the data. An observational study demonstrated improved outcomes, but the lack of a control
group and the small sample size are limitations.
Multiple sclerosis
• There is substantial evidence that oral cannabinoids are an effective treatment for improving
patient-reported multiple sclerosis spasticity symptoms, but limited evidence for an effect on
clinician-measured spasticity.
Based on evidence from randomized controlled trials included in systematic reviews, an oral
cannabis extract, nabiximols, and orally administered THC are probably effective for reducing
patient-reported spasticity scores in patients with MS. The effect appears to be modest. These
agents have not consistently demonstrated a benefit on clinician-measured spasticity indices.
Medical conditions of same kind or class as or comparable to the above
qualifying medical conditions
• The qualifying physician has provided the patient or the patient's parent or legal guardian a
summary of the current research on the efficacy of marijuana to treat the patient's medical
condition.
• The summary is attached to this informed consent as Addendum
Terminal conditions diagnosed by a physician other than the qualified
physician issuing the physician certification
• The qualifying physician has provided the patient or the patient's caregiver a summary of the
current research on the efficacy of marijuana to treat the patient's terminal condition.
• The summary is attached to this informed consent as Addendum
Chronic nonmalignant pain
• There is substantial evidence that cannabis is an effective treatment for chronic pain in adults.
The majority of studies on pain evaluated nabiximols outside the United States. Only a handful
of studies have evaluated the use of cannabis in the United States and all of them evaluated
cannabis in flower form provided by the National Institute on Drug Abuse. In contrast, many of
the cannabis products that are sold in state-regulated markets bear little resemblance to the
products that are available for research at the federal level in the United States. Pain patients
also use topical forms.

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While the use of cannabis for the treatment of pain is supported by well controlled clinical
trials, very little is known about the efficacy, dose, routes of administration, or side effects
of commonly used and commercially available cannabis products in the United States.
h. That the patient's de-identified health information contained in the physician
certification and medical marijuana use registry may be used for research
purposes.
The Department of Health submits a data set to the Consortium for Medical Marijuana Clinical
Outcomes Research for each patient registered in the medical marijuana use registry that includes
the patient's qualifying medical condition and the daily dose amount and forms of marijuana certified
for the patient.

PART B: Certification for medical marijuana in a smokable form for a patient under 18
with a diagnosed terminal condition.
___ Initial here if you are not a patient under 18 with a diagnosed terminal condition who will be receiving
medical marijuana in a smokable form. After initialing here, complete part C.
If the patient is under 18, has a diagnosed terminal condition, and will be receiving medical marijuana
in a smokable form, please review and initial the remainder of Part B before completing Part C.
Respiratory Health
___ Exposures to tobacco smoke and household air pollution consistently ranks among the top risk factors
not only for respiratory disease burden but also for the global burden of disease. Given the known
relationships between tobacco smoking and multiple respiratory conditions, one could hypothesize that
long-term cannabis smoking leads to similar deleterious effects of respiratory health, and some
investigators argue that cannabis smoking may be even more harmful than that of tobacco smoking.
Cognitive and Psychosocial Development
____ Researchers are still studying the long-term health effects of marijuana. Most people agree that
marijuana use hurts adolescents more than adults. It is during the period of adolescence and young
adulthood that the neural substrates that underlie the development of cognition are most active.
Adolescence marks one of the most impressive stretches of neural and behavioral change with
substantial a protracted development in terms of both brain structure and function. As a result,
cannabis and other substance use during this period may incur relatively greater interference in
neural, social, and academic functioning compared to late developmental periods (e.g. adulthood).
• There is moderate evidence of a statistical association between acute cannabis use and
impairment in the cognitive domains of learning, memory, and attention.
• There is limited evidence of a statistical association between cannabis use and impaired academic
achievement and education outcomes.
• There is limited evidence of a statistical association between cannabis use and increased rates of
unemployment and/or low income.

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• There is limited evidence of a statistical association between cannabis use and impaired social
functioning or engagement in developmentally appropriate social roles.

Addiction
____ Marijuana, like some other brain-altering substances, can be addictive. Nearly one in 10 marijuana users
will become addicted. Starting to use marijuana at a younger age can lead to a greater risk of developing
a substance use disorder later in life. Adolescents who begin using marijuana before age 18 are four to
seven times more likely than adults to develop a marijuana use disorder.

Part C: Must be completed for all medical marijuana patients

I have had the opportunity to discuss these matters with the physician and to ask questions
regarding anything I may not understand or that I believe needed to be clarified. I acknowledge
that Dr. has informed me of the nature of a recommended treatment,
including but not limited to, any recommendation regarding medical marijuana.

Dr. also informed me of the risks, complications, and expected benefits of any
recommended treatment, including its likelihood of success and failure. I acknowledge that Dr.
informed me of any alternatives to the recommended treatment, including the
alternative of no treatment, and the risks and benefits. Dr. has
explained the information in this consent form about the medical use of marijuana.
Patient (print name)
Patient signature or signature of the parent or legal guardian if the patient is a minor:

Date

I have explained the information in this consent form about the medical use of marijuana to

(Print patient name).

Qualified physician signature:

Date

Witness:

Date