Medical Card

WE MAKE IT SIMPLE!

Our goal is to assist you in obtaining a medical recommendation for your Arizona Medical Cannabis Card.

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.

 

PRICE: 199$

 

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:


 

Liability Waiver and Release


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.

I understand and acknowledge that:

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.

PATIENT INFORMED CONSENT AND CONTRAINDICATIONS & SIDE EFFECTS ACKNOWLEDGMENT


Please read to understand and agree.

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)

Glaucoma

Post-Traumatic Stress Disorder (PTSD)

Severe and Chronic Pain

Seizures, including epilepsy characteristics

Crohn’s Disease

Agitation of Alzheimer’s Disease

Cancer

Hepatitis C

Cachexia or Wasting Syndrome

Severe Nausea

Severe or persistent muscle spasms, including those characteristic of multiple sclerosis

  • If I begin to experience respiratory problems or any other ill effects and I will discontinue the use of medical marijuana.
  • The Staff Physician is addressing one specific aspect of my medical care for medical marijuana and unless otherwise stated, is not establishing himself as my primary physician unless specifically requested and the proper paperwork is completed.
  • The Staff Physician is not advising nor condoning the discontinuation of treatment or medication that I am currently taking.
  • I give my consent to have my name, date of visit and other required information released for the legal verification of my certification as needed.
  • I have had the opportunity to discuss these matters with the Staff Physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified.
  • I understand that smoking marijuana may cause respiratory harm such as bronchitis. Some researchers believe that marijuana smoke contains chemicals that can cause lung disease and that smoking marijuana may increase the risk of respiratory illness and disease of the lungs, throat, mouth and tongue.
  • I understand the potential dangers to fetuses caused by smoking or ingesting marijuana white pregnant or to infants while breastfeeding. I also understand that the use of marijuana during pregnancy may result in a risk of being reported to the Department of Child Safety during the pregnancy or at the birth of the child by persons who are required to report.

Possible side effects of medical marijuana may include, but are not limited to:

Anxiety

Inability to concentrate

Difficulty in completing complex tasks

Sedation

Alterations in the perception of time and space

Impairment of motor skills, reaction time, & physical coordination

Low blood pressure

Dizziness

Increased talkativeness

Impairment of short-term memory

Confusion

Euphoria

Tachycardia and heart palpitations

Cough

Sore throat

Laryngitis

Bronchitis

General Apathy

Paranoia

Suppression of the body’s immune system

Psychotic symptoms

Cannabinoid Hyperemesis Syndrome

I understand that side effects, while rare, may occur while I am using medical marijuana. These side effects have  been explained to me.

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.

Symptoms of withdrawal, while generally mild, can include:

Feelings of depression, sadness or irritability

Insomnia

Sleep disturbances

Unusual tiredness

Trouble concentrating

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.

WHAT MEDICAL CONDITIONS WILL QUALIFY A PATIENT FOR MEDICAL CANNABIS?


  • Cancer
  • Glaucoma
  • Human Immunodeficiency Virus (HIV)
  • Acquired Immune Deficiency Syndrome (AIDS)
  • Hepatitis C
  • Amyotrophic Lateral Sclerosis (ALS)
  • Crohn’s Disease
  • Agitation of Alzheimer’s disease
  • Post-Traumatic Stress Disorder (PTSD)

A chronic or debilitating disease or medical condition or the treatment for a chronic or debilitating disease or medical condition that causes:

  • Cachexia or wasting syndrome
  • Severe and chronic pain
  • Severe nausea
  • Seizures, including those characteristic of epilepsy
  • Severe or persistent muscle spasms, including those characteristic of multiple sclerosis

WHAT DO I NEED FOR A MEDICAL CANNABIS CERTIFICATION?


A valid Arizona State ID, Arizona Driver’s License or US Passport

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