Medical Marijuana Written Documentation of Patient's Medical Records
State of California¡ªHealth and Human Services Agency
California Department of Public Health
Medical Marijuana Program
WRITTEN DOCUMENTATION OF PATIENT¡¯S MEDICAL RECORDS
(Please Print)
Note to Attending Physician: This is not a mandatory form. If 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).
Attending physician name
California medical license number
Service mailing address (number, street)
Office telephone number
(
City
State
ZIP code
)
Office fax number
(
)
Licensed by (check one):
Medical Board of California
Osteopathic Medical Board of California
California Board of Podiatric Medicine
is a patient under the medical care and supervision of the above
Patient¡¯s name
named physician who has diagnosed the patient with one or more of the following medical conditions:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Acquired Immune Deficiency Syndrome (AIDS)
Anorexia
Arthritis
Cachexia
Cancer
Chronic pain
Glaucoma
Migraine
Persistent muscle spasms, including, but not limited to, spasms associated with multiple sclerosis
Seizures, including, but not limited to, seizures associated with epilepsy
Severe nausea
Any other chronic or persistent medical symptom that either:
a. Substantially limits the ability of the person to conduct one or more major life activities as defined in the Americans with
Disabilities Act of 1990.
b. If not alleviated, may cause serious harm to the patient¡¯s safety or physical or mental health
ATTENDING PHYSICIAN STATEMENT:
This patient has been diagnosed with one or more of the foregoing medical conditions and the use of medical
marijuana is appropriate.
Attending physician¡¯s signature
Telephone number
Original¡ªPatient
CDPH 9044 (4/18)
Copy¡ªPatient¡¯s File
Date
................
................
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