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Welcome to Dr. Lawrence Birnbaum's Online Medical Marijuana Certification System
PATIENT INFORMATION
First Name
Last Name
Email
Phone
Drivers Lic. or State ID
Gender
Referred By
Address
Unit or Apt#
City
State
Zip Code
QUALIFYING CONDITIONS
Please indicate if you have had any of the following symptoms consistently
CALIFORNIA medical cannabis qualifying conditions shown below:
Check each medical problem that you suffer from or check other to have the doctor evaluate your unique condition. At least one box must be checked to qualify.
UPLOAD DRIVERS LIC. OR STATE ID
In order to verify your legal name and identity, you must upload a government-issued photo ID such as a driver license or passport.
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Notice To Consumers

The Compassionate Use Act of 1996 ensures that seriously ill Californians have the right to obtain and use cannabis for medical purposes where medical use is deemed appropriate and has been recommended by a physician who has determined that the persons health would benefit from the use of medical cannabis. Recommendations must come from an attending physician as defined in Section 11362.7 of the Health and Safety Code. Cannabis is a Schedule I drug according to the federal Controlled Substances Act. Activity related to cannabis use is subject to federal prosecution, regardless of the protections provided by state law.

DISQUALIFIERS

I UNDERSTAND THAT I MUST PHYSICALLY BE WITHIN THE STATE OF CALIFORNIA AT THE TIME OF STARTING & COMPLETING THIS APPLICATION. I UNDERSTAND THAT IF I AM NOT IN THE STATE OF CALIFORNIA, I WILL BE DISQUALIFIED. I UNDERSTAND THAT MEDICINAL CANNABIS IS A CONTROLLED SUBSTANCE UNDER STATE LAW AND PROHIBITED UNDER FEDERAL LAW. I UNDERSTAND THAT THE MEDICAL GROUP DOES NOT RECOMMEND THE USE OF CANNABIS UNDER ANY TYPE OF PROBATION OR PAROLE. I UNDERSTAND THAT IF I AM ON ANY TYPE OF PROBATION OR PAROLE, I CAN BE DISQUALIFIED. I UNDERSTAND THAT THE CONSUMPTION OF ALCOHOL UNDER THE AGE OF 21 IS PROHIBITED BY THE NATIONAL MINIMUM DRINKING AGE ACT. I ACKNOWLEDGE THAT USING ALCOHOL AS A MINOR IS IN VIOLATION OF FEDERAL AND STATE LAW AND QUALIFIES AS HIGH-RISK BEHAVIOR. I UNDERSTAND THAT IF I AM CONSUMING ALCOHOL AS A MINOR, I CAN BE DISQUALIFIED. I UNDERSTAND THAT USE OF CANNABIS IS NOT RECOMMENDED DURING PREGNANCY, CONCEPTION OR BREASTFEEDING. I UNDERSTAND THAT IF I AM PREGNANT, BREASTFEEDING, OR TRYING TO CONCEIVE (WHETHER MALE OR FEMALE), I CAN BE DISQUALIFIED. With my signature, I acknowledge that I have read the above requirements for disqualification, and that I understand and agree with all of the aforementioned statements listed.

HIPAA Information For Patient

Please read each item below and check (in the space provided) to indicate that you have read the information regarding the risks and side effects of using cannabis. 1. The use of cannabis is illegal under both State and Federal law. Proposition 215: California's Compassionate Use Act and SB 420: California's Medical Marijuana Program Act, provides protection from criminal prosecution for patients who qualified under their state approved Medical Marijuana Program. 2. I understand that cannabis is not approved under The Food and Drug Administration (FDA) and therefore may contain unknown quantities of active ingredients, impurities and/or contaminants. 3. Effects and potency of cannabis varies widely depending on the cannabis strain and ingestion method. 4. The following are possible side effects related to the use of cannabis; including but not limited to: 1) Agitation/irritability 2) Anxiety attack 3) Apathy 4) Bronchitis 5) Changes in sleep patterns 6) Confusion 7) Cough 8) Dependency 9) Depression 10)Difficulty completing complex tasks 11)Dizziness 12)Drowsiness 13)Dry mouth 14)Feeling of euphoria 15)Headache 16)High/low blood pressure 17)Hunger 18)Impaired vision 19)Impairment of motor skills, coordination, and reaction time 20)Inability to concentrate 21)Insomnia 22)Irregular heart beat 23)Laryngitis 24)Loss of appetite 25)Nausea/Vomiting 26)Numbness 27)Paranoia, psychotic symptoms 28)Poor physical coordination 29)Sedation 30)Short term memory loss 31)Shortness of breath 32)Suppression of immune system 33)Talkativeness 34)Tiredness 35)Trouble concentrating

Release Of Liability

I hereby state that I fully understand the potential risks and side effects related to the use of cannabis and in using cannabis therapeutically, I accept full responsibility in assuming the risks and side effects related to its use. I understand there is no representation on the medical efficacy of marijuana by the doctor or the doctor's office staff. I agree to allow communication regarding my personal health information (PHI) via email and/or SMS from the medical group, which includes the doctor, the medical staff, the principals, the agents and the employees. I understand that the doctor is NOT my primary care provider. I agree that the doctor and/or principals, agents, and employees, shall not be held responsible for any harm resulting to me and/or other individuals as a result of my medicinal use of cannabis. If I have legal issues with regards to marijuana usage, I will consult with my attorney and law enforcement personnel. If I have work-related questions or concerns, I will consult with the Human Resources Department at my workplace immediately. With my signature, I acknowledge that I have read the above requirements and that I understand and agree with all of the aforementioned statements listed.

PATIENT SIGNATURE
Filling out this form does not guarantee a medical cannabis recommendation and your recommendation may be revoked at any time if you have perjured yourself on this form.
By electronically signing this document, you declare under penalty of perjury that the information on this form is true and correct.

Use your mouse, finger or stylus to add your signature.