DOC request three complete - Cannabis Defense Coalition

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OFFENDEllI.D. DATA'
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STATEOFWASHINGTON
......, DEPARTMENT OF. CORREC110NS
Medicinal Use of Marijuana Verification
To be filled out by Prescriber:
Dear Prescriber,
By state statute the Washington State Department of Corrections is charged with the responsibility to supervise some
offenders after they have been convicted of a felony. The above named patlent is currently under supervision by the
Department. Supervision is designed to help the offender. avoid t~ose environments or situations that lead to the.ir criminal
·behavior. Often illicit drug use is a oontributing factor in an individual's crIminalitY. Aocordingly it's usual that the court or
the Department of Corrections will impose a condttion of supervision that the offender !lot use, or possess illicit drugs,
including marijuana. This offender has 'claimed that they have a condition for which the medicinal use of marijuana has
been recommended. The below verification is to determine the legitimacy of their claim. Thank you in OIdvance for your
aSSistance. If you have questions please feel free to personally contact the Medical. Director of the Department at (360)
725~8700.
1. Is this patient unqer your care
2. Are you recommending medical marijuana for his patient due to a diagnosis of Acquired
Immunodeficiency Syndrome (AIDS)
a. If the answer to question 2 is "Yes·, does helshe have anorexia
b. 'If the answer to que~tion' 2a is "Yes·, does helshe have weight loss
~es
~Yes
DYes
DYes
ONo
E:rNo
r:rt'io
[31iIo
3. Are you recommending medical marijuana for this patient due to nausea and vomiting 0 Yes B'folo
associated with cancer chemotherapy
a. If the answer to question 3 is "Yes·, has the patient failed to respond to conventional 0 Yes ~o·
. antiemetic treatments . .
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4.
. c.
a.
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What is the planned schedule of che.7therapy
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If you answered "No" to items 2 .& 3 above, what is thirea:r~u are. recomm~i~g medicinal use of
marijuana C l.. ('"()h ; t. P Co. i k.. - S "'~ . ~ s v.-V"3~,{ (
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