Form Rpd-41131 - Missouri Hemp Extract Registration Card Neurologist Certification - Missouri Department Of Health And Senior Services

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Date Received
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
DIVISION OF COMMUNITY AND PUBLIC HEALTH
MISSOURI HEMP EXTRACT REGISTRATION CARD
NEUROLOGIST CERTIFICATION
PATIENT INFORMATION (please print or type)
Patient Full Legal Name (last name, first name, and middle name) (include suffixes, i.e., Junior, Senior, II, III, etc.)
Date of Birth
Gender
Male
Female
Address
City
State
Zip Code
Race
Ethnicity
Asian/Native Hawaiian/Pacific Islander
White
Hispanic
African American/Black
Mixed Race
Non-Hispanic
American Indian/Alaskan Native
Other
NEUROLOGIST STATEMENT
I am a physician licensed under Chapter 334, RSMo, and am board certified in neurology.
I have overseen three (3) or more treatment options for the patient listed above and have determined the
patient does not respond to those options.
The patient listed above suffers from intractable epilepsy and may benefit from treatment with hemp extract as
evidenced by the attached copy of a record of my evaluation and observation of the patient relating to the
patient’s treatment for intractable epilepsy.
I understand that I am required to keep a record of my evaluation and observation of the patient, including the
patient’s response to hemp extract, and to transmit the record of my evaluation and observation of the patient
to the Department of Health and Senior Services.
NEUROLOGIST INFORMATION (please print or type)
Name
Degree
Address
City
State
Zip Code
Missouri License Number
Telephone Number
NEUROLOGIST SIGNATURE (original signature required)
Date
This form must be submitted to the Department of Health and Senior Services by the patient (or if the patient is
a minor, the patient’s parent or legal guardian) with the Missouri Hemp Extract Registration Card Application.
MO 580-3084
10-14

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