Patient Evaluation and Medical Marijuana Informed Consent Companion

Patient name: __________________________________________

Date of birth: __________________ Visit date: __________________

Qualified physician: _____________________________________________

Purpose of the evaluation

I request an individual medical evaluation to determine whether I meet applicable Florida requirements for a medical marijuana physician certification. I understand that an evaluation may include review of my medical history, prior records, current conditions, medications, and other information the physician considers clinically necessary.

I understand that the physician makes an independent decision. An appointment, payment, prior certification, or completion of forms does not guarantee a new or renewed certification, approval of a specific route or amount, or issuance of a state registry identification card.

Information I will provide

I will provide accurate information about my symptoms, diagnoses, prior treatments, medical and mental health history, medications, supplements, allergies, and relevant substance use. I will tell the physician about changes that may affect my care. I understand that the physician may need supporting records or an additional evaluation before making a decision.

Discussion with the physician

If medical marijuana is considered, I will have an opportunity to discuss its potential benefits, known and uncertain risks, alternatives, medication interactions, impairment, safe storage, and questions relevant to my circumstances. I understand that I should not drive or operate machinery while impaired.

I understand that a physician certification is not a guarantee of treatment results and does not replace continuing care from my other clinicians. Haven does not dispense medical marijuana. Products, identification cards, and related state fees are handled separately through the applicable state process and licensed entities.

My choice

I may ask questions and decline a proposed certification or treatment. I understand that any certification requires the separate, current Florida Medical Marijuana Consent Form, discussed with and obtained by the qualified physician as required by law.

Patient or authorized representative signature: ______________________________

Date: __________________

If signed by a representative

Printed name: _________________________________________________

Relationship and legal authority: _________________________________

Physician

Physician name and signature: ____________________________________

Date: __________________

State-required Medical Marijuana Consent Form completed for this certification?

☐Yes ☐ No certification issued