ATTENDING PHYSICIAN'S STATEMENT -- NEW Application
Oregon Medical Marijuana Program
Instructions: Please complete all required information in order to comply with the registration requirements of the Oregon Medical Marijuana Act OR provide relevant portions of the patient's medical record containing all information required on this form. This does not constitute a prescription for marijuana.
If you need this document in an alternative format, please call: 503-731-4002 x 233
 
  PATIENT INFORMATION
A PATIENT NAME (LAST, FIRST, M.I.) DATE OF BIRTH:
 MAILING ADDRESS: TELEPHONE NUMBER:
 (        )
 CITY, STATE, AND ZIP CODE:
 
  PHYSICIAN INFORMATION
B PHYSICIAN NAME (Please print legibly) DATE OF BIRTH:
 MAILING ADDRESS: TELEPHONE NUMBER:
 (        )
 CITY, STATE, AND ZIP CODE:
C
  PHYSICIAN'S STATEMENT
  Debilitating Medical Condition: Check appropriate boxes.
 [   ] 1. Malignant neoplasm (Cancer)
 [   ] 2. Glaucoma
 [   ] 3. Positive status for Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)
 [   ] 4. Agitation due to Alzheimer’s Disease
 [   ] 5. A medical condition or treatment for a medical condition that produces for a specific patient
       one or more of the following: (check all that apply)
       [   ] a. Cachexia
       [   ] b. Severe pain
       [   ] c. Severe nausea
       [   ] d. Seizures, including but not limited to seizures caused by epilepsy
       [   ] e. Persistent muscle spasms, including but not limited to spasms caused by multiple sclerosis
 Comments:
       
       
       
I hereby certify that I am a physician duly licensed to practice medicine in Oregon under ORS Chapter 677. I have primary responsibility for the care and treatment of the above-named patient. The above-named patient has been diagnosed with a debilitating medical condition, as listed above. Marijuana used medically may mitigate the symptoms or effects of this patient's condition. This is not a prescription for the use of medical marijuana.
 PHYSICIAN'S SIGNATURE: DATE:
  
  MAIL ATTENDING PHYSICIAN'S STATEMENT TO:DHS/OMMP
PO Box 14450
Portland, OR 97293-0450