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Michigan Department of Community Health

DCH/MMP-020 (3/09)

Michigan Medical Marihuana Registry

P.O. Box 30083

Lansing, MI 48909

Physician Certification #1

INSTRUCTIONS: Please complete all of the information required on this form OR provide relevant portions of the

patient’s medical record that contain all the information required on this form. Sign the form and keep a copy in the

patient’s medical record. The patient will submit this certification along with his/her application for a Michigan Medical

Marihuana Registry identification card. This does not constitute a prescription for marihuana. You may contact the

Michigan Medical Marihuana Registry at (517) 373-0395 if you have any questions or concerns.

PLEASE TYPE OR PRINT LEGIBLY

PATIENT INFORMATION: (REQUIRED)

Name (Last, First, M.I.)

DATE OF BIRTH

PHYSICIAN INFORMATION: (REQUIRED)

Name (Last, First, M.I.)

TELEPHONE NUMBER

(

)

MAILING ADDRESS

MI LICENSE NUMBER

CITY

STATE

ZIP CODE

EMAIL ADDRESS

(Optional)

PHYSICIAN’S STATEMENT: (REQUIRED)

The above-named patient has been diagnosed with and is currently undergoing treatment for the following debilitating

medical condition (check appropriate boxes):

Cancer

OR a medical condition or treatment that produces, for this

patient, one or more of the following and which, in the

Glaucoma

physician’s professional opinion, may be alleviated by the

HIV or AIDS Positive

medical use of medical marihuana.

Hepatitis C

Cachexia or Wasting Syndrome

Amyotrophic Lateral Sclerosis

Severe and Chronic Pain

Crohn’s Disease

Severe Nausea

Agitation of Alzheimer’s Disease

Seizures (Including but not limited to those

Nail Patella

characteristic of Epilepsy.)

Severe and Persistent Muscle Spasms (Including

but not limited to those characteristic of Multiple

Sclerosis.)

Comments: (Please Type or Print Legibly)

SIGNATURE & DATE: (REQUIRED)

I hereby certify that I am a physician licensed to practice medicine in Michigan. I have responsibility for the

care and treatment for the above-named patient. It is my professional opinion that the applicant has been

diagnosed with a debilitating medical condition as indicated above. The medical use of marihuana is likely to

be palliative or provide therapeutic benefits for the symptoms or effects of applicant’s condition. This is not

a prescription for the use of medical marihuana.

__________________________________________________________________________

_____________________

Physician’s Signature

Date

Provide the name and telephone number of office contact to verify validity of certification:

(

)

(Name – Please Print)

(Telephone Number)

Application Form For Registration Of Minor Patient Form - Michigan Department Of Community Health Page 3

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