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Medical Marijuana Consent Form |

A qualified physician/provider 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/provider explained the information and, along with the qualified physician/provider, must sign and date the informed consent form.

  • a. The Federal Government's classification of marijuana as a Schedule I controlled substance.

  • b. The approval and oversight status of marijuana by the Food and Drug Administration.

  • c. The potential for addiction.

  • 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.

  • e. The potential side effects of medical marijuana use.

  • f. The risks, benefits, and drug interactions of marijuana.

  • g. The current state of research on the efficacy of marijuana to treat the qualifying conditions set forth in this section.

  • Cancer
  • 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 insufficient evidence to support or refute the conclusion that cannabinoids are an effective treatment for cancer-associated anorexia-cachexia syndrome and anorexia nervosa.
  • 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
  • Lower intraocular pressure is a key target for glaucoma treatments. Non­ randomized 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 continug1I rather than transient reductions in intraocular 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 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 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
  • 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
  • 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
  • Some studies suggest that marijuana in the form of cannabidiol may be beneficial in the treatment of inflammatory bowel diseases, including Crohn's disease.
  • Parkinson's disease
  • 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
  • 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.
  • • The qualifying physician/provider 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._
  • • The qualifying physician/provider 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
  • 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. 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/provider certification and medical marijuana use registry may be used for research purposes.

  • PART B: Certification for medical marijuana in a smokable form for a patient under 18 with a diagnosed terminal condition.

  • Respiratory Health

  • Cognitive and Psychosocial Development

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

  • Addiction

  • PART C: For certification of smoking marijuana as an appropriate route of administration for a qualified patient, other than a patient diagnosed with a terminal condition

  • Smokable marijuana has infectious risks that are not present in processed products. Certain molds and mildews can contaminate marijuana plants during growing, processing, storage in dispensaries and in patient homes. These contaminates can pose health risks, particularly to those who are immunosuppressed due to their disease state and treatments. While the most states require third party testing you should still inspect your product.
  • 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 relations ships between tobacco smoking and multiple respiratory conditions, one could hypothesize that long‐term marijuana smoking leads to similar deleterious effects of respiratory health, and some investigators ague that marijuana smoking may be even more harmful that of tobacco smoking.
  • You should never smoke medical marijuana around other family members, especially children and any household guests. You should smoke outside to allow adequate ventilation and to mitigate the dangers of secondhand and thirdhand smoke to others. Marijuana should never be smoked inside vehicles or other small spaces that children will occupy even if the children are not present at the time the product is consumed.
  • If you use oxygen or have others in your household who use oxygen you should not smoke marijuana or any other combustible material in the vicinity of where the oxygen is in use due to the risk of fire and explosion. Self‐dosing, if ermitted. I have been given instructions or discussed guidance on self‐ dosing with my qualified physician if permitted to do so.
  • I have been given instructions or discussed guidance on self‐ dosing with my qualified physician if permitted to do so.

  • PART D: Must be completed for all medical marijuana patients

  • My treating physician/provider also informed me of the risks, complications, and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that my treating physician/provider informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits. My treating physician/provider has explained the information in this consent form about the medical use of marijuana.