Written Certification Form

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State of Illinois
Illinois Department of Public Health
Illinois Medical Cannabis Pilot Program
Reviewing Physician Written Certification Form
for Qualifying Patients Under 18 Years of Age
INSTRUCTIONS
Type or print clearly and answer all of the questions. This certification does not constitute a prescription
for medical cannabis.
THIS MUST BE MAILED BY THE REVIEWING PHYSICIAN – DO NOT GIVE TO THE PATIENT
Mail this form to:
Illinois Department of Public Health
Division of Medical Cannabis
535 West Jefferson Street
Springfield, Illinois 62761-0001
The reviewing physician written certification form is required for qualifying patients under 18 years of age.
QUALIFYING PATIENT INFORMATION
First Name
Middle Name
Last Name
Home Address
Apartment or Suite #
City
State
ZIP Code
IL
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
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Printed by Authority of the State of Illinois
IOCI 15-164
P.O.#3115003
2M
9/14

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