We provide you with a professional, confidential environment to complete your medical evaluation and application process.
To apply for a medical cannabis card, Arizona law requires a physician to complete a medical evaluation. We will conduct the required medical review of your qualified health condition.
Content of the Medical Cannabis Card Form you can read below.
If you want to download Medical Cannabis Card Form you can do it here:
In consideration of the medical evaluation of me to be performed by or on behalf of Pima Neurology, I, my heirs, assigns and anyone acting on my behalf, agree to hold the Pima Neurology Staff Physicians, and their principals, agents, officers, directors and employees, free and harmless from any and all claims, damages and causes of action relating to or arising out of: (1) my use or possession of cannabis (marijuana), or (2) the denial of my application for a medical marijuana card for any reason.
1. It is my responsibility to be informed regarding State and Federal laws regarding the possession, use, sale/purchase and/or distribution of marijuana.
2. Pima Neurology is not a Dispensary and cannot provide me with medicinal marijuana or any other medication.
3. An evaluation that results in a physician’s recommendation that I may benefit from the use of medicinal marijuana does not guarantee that I will in fact be eligible to obtain, possess or use medicinal marijuana pursuant to Arizona law.
4. A physician’s recommendation that I may benefit from the use of medicinal marijuana does not guarantee that the use of medicinal marijuana will be effective at alleviating my pain; or any other medical condition.
5. I acknowledge that my employer or occupation may prohibit me from the use of medical marijuana even though I have state certification.
6. Should an approval be made for my medicinal use of medical marijuana, there is a renewal date specified by the state. It is my responsibility to see the physician to assess the possible continuance of medical marijuana use beyond the term of the approval.
7. I am a resident of Arizona, I am at least 18 years of age and have not misrepresented any information to Pima Neurology. If I am under 18 years of age, I must have parental consent and authorization for the use of medical marijuana.
8. I acknowledge that I am not recording any portion of my visit with Pima Neurology. I understand that Pima Neurology does not allow any recordings. Any such action is a direct violation of HIPAA regulations and patient/ doctor confidentiality.
9. I acknowledge that marijuana, even if used for medical purposes, is illegal under Federal law.
10. I acknowledge that the use of medical marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. While using marijuana I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/ or respond quickly. I understand that if I drive while under the influence of medical marijuana, I can be arrested for “driving under the influence”.
11. I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.
I understand that medical marijuana is considered a medicine and is to be used in treating the suffering caused by serious and debilitating medical conditions. Serious and debilitating medical conditions include:
Acquired Immune Deficiency Syndrome (AIDS)
Amyotrophic Lateral Sclerosis (ALS)
Human Immunodeficiency Virus (HIV)
Post-Traumatic Stress Disorder (PTSD)
Severe and Chronic Pain
Seizures, including epilepsy characteristics
Agitation of Alzheimer’s Disease
Cachexia or Wasting Syndrome
Severe or persistent muscle spasms, including those characteristic of multiple sclerosis
Inability to concentrate
Difficulty in completing complex tasks
Alterations in the perception of time and space
Impairment of motor skills, reaction time, & physical coordination
Low blood pressure
Impairment of short-term memory
Tachycardia and heart palpitations
Suppression of the body’s immune system
Cannabinoid Hyperemesis Syndrome
The potency and effects of medical marijuana varies. Estimating the proper marijuana dosage is very important. Some patients may become dependent on marijuana and could experience withdrawal symptoms when they stop.
Feelings of depression, sadness or irritability
Loss of appetite
I understand that the cannabis plant is not a food crop and therefore is not regulated by the U.S. Food & Drug Administration and may contain unknown quantities of impurities, active ingredients and/or contaminants. While under the influence of marijuana, the use of alcohol is not recommended. The possibility exists that medical marijuana may exacerbate psychotic problems.
A valid Arizona State ID, Arizona Driver’s License or US Passport