DOC request three complete - Cannabis Defense Coalition

Documentation of Medical Authorization to
Possess Marijuana for Medical Purposes in Washington State
Patient name
Date of birth --=-.*'6
I
!.
· Under Washington. state law, the use of medical marijuana is now permissible for so me patients
· with ter!TIinal or depilitating illnesses. The law regulating this (RCW 69.51 A) allows physicians to
advise patients about the risks and benefits of the medical use of marijuana. The medical and
· scientific evidence supporting the use of medical marijuana remains controversial in the medical
community. Not all hE:alth care providers beUeve th~t medical marijuana is safe or effective and
some providers feel that it is a dangerous drug. According t9 the Washington state law, the ben-
efits of medical marijuana may include treating nausea and vomiting from 2hemotherapy; AIDS
wasting syndrome; severe muscle spasms from mUltiple sclerosis !=ir other spasticity disorders;
i .
I'
I am a physician licensed in the State of Washington. I am treating the abve named patient
for a terminal iilne~s or debilit~ting condition as defined in RCW 69.51A.01 O. I have advised the
above named patient about the pqtential risks arid be1efits of the medical use of mqrijuana.1 have
assessed the aboye named pat.ient's medical history and medical condition. It is my medical
opinion that the potential benefits of the medical use of marijuana would likely outweigh the
health risks for this fatieot. .' ~.. . . . '.
~~~ .. ~o~ S
Signature of physician . ~ 'Q:tl\ef; p.., 'S-1:
, . lC a
. . (1'\ (> ~p ~ ~t_.
Printed name of physician ~c.~.A. 't l ~~ Src ~cc~6 L~'
Risks and ben!!fits of medical marjjuana
, . seB1~' 3/7/0 ('[ .
, r-f2
! glaucoma;and some types of intractable pain. Some of the risks'of medical marijuana may in-
'
elude possible long-term effects on the brain in the areas of memory, coordination' and cognitioni
\
impairment of the ability to drive or operate heavy machineryi respiratory damage; possible lung
\ ~ __ ~-----=c=an=c=e=~=.a=n~d_p_h_y_S_iC_a~lo_r_p=s=y=C=hO='=O=9~ic=a='d=e=p=e=n=d=e=n=ce=.====::::==::==========:====:::=:==~~======~ __ ----
This Form provided 0)1 the Washington State Medical Association
PDU-6655-3 000148