Patient Questionnaire

Filling out this form does not guarantee an approval or recommendation for the use of medicinal cannabis.

STEP 1 - PATIENT INFORMATION
STEP 2 - SAVE YOUR INITIALS
Use your mouse or finger to sign below. Click "Add Initials" after signing.
STEP 3 - ADD INITIALS BELOW
The cultivation, possession and use of cannabis, even for medical purposes is still currently illegal under federal law. Physicians licensed in Florida may discuss and approve the medical use of cannabis to patients suffering from a qualifying medical condition. Dr. Stein and the staff are neither dispensing nor providing or encouraging me to obtain medical cannabis. Doing so would be a violation of federal law. Please do not ask the doctor where to obtain medical cannabis. Please visit the internet and front counter for additional literature.
Dr.Stein and his staff are addressing specific aspects of my medical care and are in no way establishing themselves as my primary care provider. I agree to follow up with Daniel P. Stein, MD, with supporting updated medical records pertaining to my condition. These documents can be brought in person, mailed, faxed or emailed. Our contact information will be provided to you at the end of your visit.
I understand that Dr. Stein does not suggest nor condone that I cease treatment and/or medication that is prescribed to stabilize my physical or mental condition.
I hereby declare that I have truthfully and completely disclosed all information regarding my medical condition. I attest that I do not intend to use my medical recommendation for illegal purposes.
I attest that I am not a member, employee or agent of any media or law enforcement agency. It is illegal to film or record in this office with a video camera, cell phone or any other recording device. This is a direct violation of HIPAA regulations and doctor/patient confidentiality.
I am aware that my recommendation can be revoked at any time if I have misrepresented myself or my condition, my intentions or falsified any medical records to the physician.
I hereby authorize Daniel P. Stein, MD to discuss my medical condition for verification purposes only.
I hereby acknowledge that I have read and understand the HIPAA - Notice of Privacy Practices and may obtain a copy at my request.
HIPAA - Notice of Privacy Practices
Neurology Of Cannabis - Release Authorization
STEP 4 - ADD ELECTRONIC SIGNATURE

I hereby authorize Daniel P.Stein, MD to verify me as a patient for the period of time for which the recommendation has been issued.

I give permission for my medical records and file to be reviewed by another physician working with Dr.Stein, if Dr.Stein needs a second opinion, is not available, off premise, or has moved or terminated his/her practice. I give Dr. Stein permission to validate my status as a patient using the secure online patient verification program. I understand that Dr. Stein will be informing me of the nature of a recommended treatment plan including, but not limited to, any recommendation regarding medical cannabis. The risks,complications, and expected benefits of any recommended treatment, including its likelihood of success and failure and any alternatives to the recommended treatment, including the alternative of no treatment, and their risks and benefits. Dr.Stein may request that I visit another physician or specialist to further substantiate my condition. I will be informed of all the above mentioned regardless of whether or not I qualify as a patient.

By electronically signing this document, YOU DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.

Please sign using a stylus, your mouse, or your finger below to sign this document. After the document is signed, you can proceed to print it or save it as PDF.

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