Michigan Medical Marihuana Program - State Of Michigan Page 3
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3MMP 3020 (Rev. 1/15)
Michigan Medical Marihuana Program
Physician Certification Form
(517) 284-6400 |
This certification must be completed and signed by a Medical Doctor or Doctor of Osteopathic Medicine and Surgery who is fully licensed by the State of Michigan
Section A: Certifying Physician Information (Required)
1. Legal First Name
2. Middle Initial
3a. Legal Last Name
3b.
Suffix (Jr., Sr., III, etc.)
4a. Full Mailing Address
4b. Apartment/Suite/Lot #
5. City
6. State
7. Zip Code
8. Telephone Number
9. Michigan Physician License Number
M.D. 4301
D.O. 5101
Section B: Patient Information (Required)
10. Legal First Name
11. Middle Initial
12a. Legal Last Name
12b. Suffix (Jr., Sr., III, etc.)
13. Date of Birth
Section C: Patient’s Debilitating Medical Condition(s) (Required)
This patient has been diagnosed with the following debilitating medical condition:
(A minimum of one box must be checked in at least one of the following categories.)
Category A
Category B
Category C
A chronic or debilitating disease or
Check and list a condition which has been
Cancer
medical condition or its treatment that
approved by the Medical Marihuana
Glaucoma
produces 1 or more of the following:
Review Panel:
HIV Positive or AIDS
Cachexia or Wasting Syndrome
Approved medical condition:
Hepatitis C
Severe and Chronic Pain
Amyotrophic Lateral Sclerosis
______________________________
Severe Nausea
Crohn’s Disease
Seizures (Including but not limited to
______________________________
Agitation of Alzheimer’s Disease
those characteristic of Epilepsy.)
______________________________
Nail Patella
Severe and Persistent Muscle Spasms
(Including but not limited to those
______________________________
characteristic of Multiple Sclerosis.)
Section D: Certification, Signature and Date (Required)
By signing below, I attest that the information entered on this certification is true and accurate. I attest that I am in compliance with the
Michigan Medical Marihuana Act, Administrative Rules, and all amendments. I attest that I have completed a full assessment of the
patient’s medical history and current medical condition, including a relevant, in-person, medical evaluation. Further, I attest that in my
professional opinion, the patient is likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate
the patient’s debilitating medical condition or symptoms associated with the debilitating medical condition.
X
:
Signature of Physician
Date:
Form Reset
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