Online MMJ Patient Information Form

Patient Information

IV Health Center / Online MMJ Patient Information Form

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Medical History

None 1-5 Times Per Month 6-15 Times Per Month 1 Time Per day More Than 1 Per Day
None Less Than Daily Daily
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Please Check All Medical Conditions You May Have In Your History

Anemia Anxiety Asthma ADD Bladder Stone Blood in Urine Blurry Vision Constipation Dental Problems Depression Diabetes Type I Diabetes Type II Disorders of Thyroid Gastric Ulcer Genital Herpes Genital Infection
Genital warts Headache Heart Palpitations Hepatitis C Herniated disc High Cholesterol High Blood Pressure HIV / Aids Excessive Sweatig Joint Pain Kidney Stones Loss of Energy Night Sweats Painful Sex Pelvic Pain Reflux Rheumatic Fever
Scoliosis Seizures Shortness of Breath Sleep Apnea STD Excess Stress TB Urinary Frequency Urinary Incontinence Urinary Infection Urinary Retention Weight Gain Blood Clot / DVT / PE Other

Please List All Surgeries

List surgery, reason for surgery, and date

Medications: Please List All Medications You Are Currently Taking

Allergies: Please List All Allergies

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Marijuana Consult Patient Information

Your consult is not billable to insurance, meaning your insurance will not cover this type of doctor visit. You are responsible for paying your exam fee prior to the day of your office visit. If you do not receive the recommendation from Dr. Ramirez, we will refund you half the amount you paid. You will not get the full amount refunded due to the time we have invested to determine whether or not you are a candidate for the recommendation. If you have any questions regarding this policy, please ask a staff member to explain.

By entering my name and the date, I acknowledge that I have read and understood the above policies and agree to abide by them.

Privacy Policy

I have been given sufficient information to make an informed decision and consent to treatment. I understand that I have the right to refuse the recommendation at any time. I acknowledge that I have read and fully understand this consent, related documents, and that all blanks or statements requiring insertion or completion were filled in before I affixed my signature. No guarantees or promises have been made to me regarding the outcome of the treatment. A copy of our HIPAA compliancy form in it’s entirety is available at the front office if you would like a copy for your records at any time.

By entering my name and the date, I acknowledge that I have read and understood the above policies and agree to abide by them.

Medical Marijuana Consent

This document represents the best available information at this time, but medical marijuana/cannabis has not been widely studied in humans and thus there may be risks or side effects that are not known and cannot be predicted. Marijuana has therapeutic effects for some patients, but is not approved as a medicine. The long-term effects are not fully understood. If you have one of the following problems than marijuana/cannabis is NOT recommended. 1. have unstable heart disease (because marijuana can increase or decrease your blood pressure or heart rate) 2. are pregnant, trying to become pregnant or breastfeeding 3. have a history of addiction to other drugs or alcohol Side effects Marijuana /cannabis should NOT be combined with alcohol or any other sedating medication. I am aware that drowsiness or clouded thinking may make it dangerous for me to drive or operate heavy machinery. Alcohol or other medications that also cause drowsiness may worsen this effect. I agree not to drive or operate heavy machinery or sign legal documents while starting marijuana/cannabis or if I feel in any way impaired from this therapy at other times, for at least for 4 hours or longer after ingesting marijuana

By entering my name and the date, I acknowledge that I have read and understood the above policies and agree to abide by them.

Medical Marijuana Side Effects

The most common side effects directly after using marijuana are dizziness, drowsiness and dry mouth. Others include feeling light-headed, headache, disorientation, feeling drunk or abnormal, feeling “too high”, feelings of unreality, feeling an extreme slowing of time, suspiciousness, nervousness, panic attacks, paranoia, hallucinations, impairment I motor skills and perception, altered body perceptions, loss of full control of body movements, falls, throat irritation, nausea, vomiting and palpitations. If you develop negative side effects, try to be calm and relax. The effects will pass within a couple of hours. Avoid strains with high THC, which are more likely to make you feel “high”. You should seek help if you have difficulty with the amount that you are using or having difficulty cutting down. Long term use may trigger or aggravate a mood disorder, increase the risk of developing chronic cough and infections (if smoking the cannabis), reduce fertility, affect the developing brain of fetus, lead to tolerance, a withdrawal syndrome and addiction. Dose related acute effects of marijuana on attention, memory and perception are clearly established. After stopping long-term heavy use, these effects on the brain may persist for days to weeks and may be accompanied by a mild withdrawal syndrome. Chronic smoking of marijuana is associated with chronic bronchitis, which causes cough and sputum. You should not give or sell medical cannabis to others, as this is both illegal and dangerous.

By entering my name and the date, I acknowledge that I have read and understood the above policies and agree to abide by them.

Warning: Drug Interactions

The following medications may increase the effects of the THC component of marijuana. Certain anti-depressants (e.g. fluoxetine, fluvoxamine, and nefazodone), ant-acids (e.g. cimetidine and omeprazole), antibiotics (e.g. clarithromycin and erythromycin), anti-fungals (e.g. itraconazole, fluconazole, ketoconazole, miconazole), calcium channel blockers used for high blood pressure and heart disease (e.g. diltiazem, verapamil), HIV protease inhibitors (e.g. ritonavir), amiodarone, and isoniazid. On the other hand, some drugs such as rifampicin, carbamazepine, phenobarbital, phenytoin, primidone, rifabutin, troglitazone, and Saint John‘s Wort may reduce the effect of THC.

By entering my name and the date, I certify that I have read and understood these risks regarding the use of medical marijuana/cannabis.

Confirming Your Electronic Signature

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I understand that my electronic signature on this form represents my handwritten signature and agree to use for the same intents and purposes.

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