I am at least 18 years of age, (or the parent or guardian for the patient), and attest to all of the following:
That I believe that I have at least one of the qualifying, debilitating medical conditions or symptoms. Further, I believe that Medical Marijuana may be able to ease my condition(s) or symptom(s). I further attest that I will be able to furnish supportive medical documentation of my condition(s) or symptoms(s) upon request.
That I have read the ”Notice of Privacy Practices” on the Doctors of Natural Medicine Website website (https://drnatmed.com/notice-of-privacy-practices/) and consent to Doctors of Natural Medicine personnel to use and/or disclose of my protected health information in the activities directly related to medical marijuana consultation, which includes, but not limited to, documentation, payments, scheduling, and quality control review.
That I understand that my consultation with one of the Doctors of Natural Medicines’ qualified providers is for the sole purpose of evaluating my medical status in regards to whether or not I may benefit from and be an appropriate candidate for the safe use of medical marijuana in accordance to my provided medical history as well as the constitutionally outlined chronic debilitating conditions and diagnoses as defined by Colorado Constitution Article XVIlI and SB-109. I further acknowledge that the provider can only make provisional diagnoses and recommendations in accordance with the aforementioned guidelines and is not providing medical treatment.
That I understand that in performing the evaluation of my medical status pertaining to the medical conditions and symptoms outlined in Article XVIII, a provider-patient relationship is established so as to determine whether a recommendation for the safe use of medical marijuana can be made. This provider-patient relationship is limited to the physician’s role as defined by Colorado Amendment 20 and will not be construed to have formed a physician-patient relationship for any other purpose.
That I understand that if the provider recommends the use of medical marijuana, that opinion does not in any way imply any specific use of marijuana. If I choose to use medical marijuana, I attest that this decision was made at my sole discretion.
That I understand that if l choose to use medical marijuana it may cause side effects, such as drowsiness, decreased reaction time, and decreased coordination; and, accordingly, I must avoid hazardous activities, such as driving a vehicle and operating any heavy machinery. I understand that using marijuana while pregnant and breastfeeding is not recommended by the provider and that there may be potential risks that cannabis poses to my unborn or newborn baby. I also understand that there may be a potential decrease in my IQ (intelligence quotient) if I use marijuana. I also understand that, as with any medication, medical marijuana may have adverse interactions with other medications and I agree to verify this with my outside prescribing physician. I further acknowledge that, as with any drug, there is a risk of dependence or addiction.
That I understand that I am consulting with a physician to obtain an opinion as to whether or not I might benefit from the medical use of cannabis. In performing an evaluation of my medical condition(s) as it relates to determining if l might benefit from the medical use of cannabis, a bona fide physician-patient relationship is established for the purpose of fulfilling the physician’s role as defined in the Colorado Medical Marijuana Amendment. Our physicians advise you to consult both with us and with your primary care provider at least once a year to re-evaluate your debilitating medical condition.
That I understand if the physician’s opinion is that medical use of cannabis may benefit me, the decision to use medical cannabis is still at my sole discretion as a patient. If l choose to use medical cannabis, I understand that cannabis may cause side effects, such as drowsiness, dizziness, decreased reaction time, and coordination. I must avoid hazardous activities, such as driving a vehicle and operating heavy machinery. when using medical marijuana.
That I understand that, as with any drug, there is a risk of dependence or addiction. If I plan to become pregnant or breastfeed, I will tell the physician and discuss the potential risks that cannabis poses to my unborn or newborn baby. Our physicians in no way imply or recommend that you purchase medicinal cannabis from any specific dispensary or caregiver.
That I, under the penalty of perjury, am registering for a medical marijuana license for my own medicinal use only. I further recognize that it is illegal for me to misrepresent myself as a patient in need of medical marijuana.
That I under penalty of perjury, am not a federal, state, county, or other law enforcement or government agent or official. l further endorse under penalty of perjury that l have not been asked or coerced to do so by any law enforcement agency, its representatives, or anyone else.
That, if I am requesting an extended plant count, I understand that I should consult with an attorney regarding my increased plant count, as this changes the defense from an exception to the criminal laws to an affirmative defense and that l have thoroughly reviewed Amendment 20, Section 18, Article 13 of the Colorado State Constitution’s provision regarding my patient right to raise an affirmative defense for having a higher plant and/or weight count in certain situations. I acknowledge that the aforementioned statement does not necessarily mean l am safe from legal consequences under Colorado law. I understand that there may be potential legal implications of having a higher plant count. I also agree to comply with all local laws, regulations, and zoning and use restrictions regarding the cultivation, growing, or production of marijuana, including the provisions of HOUSE BILL 17-1220. Further, should I be granted an extended plant count, I understand that the certifying provider may request or require more frequent follow-up than annually or more frequently at the doctor’s discretion, and if I do not attend such follow-up appointment(s) the recommending provider may revoke my extended plant. If my extended plant count is revoked, I will receive notification of the revocation of the extended plant count via a formal letter, which will also be sent to and filed with CDPHE, to be placed in my official patient record.
That I understand that my Physician Certification will be sent to the CDPHE electronically and I am responsible for maintaining my patient account and documentation. I further understand it is solely my responsibility to keep documentation of my medical marijuana recommendation on my person and with my medicine at all times.
That by booking an appointment, I agree with and consent to all statements within the entirety of this document.
