DOC request three complete - Cannabis Defense Coalition

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Documentation of Medical Authorization to Possess Marijuana
for Medical Purposes in Washington State
PATIENT NAME: __ _
_ __ ,DATE OF BIRTH: -..!!!!!!!!!!!!I!!!I!!!!.::..::..:....:=--
I. Antoine Johnson . am a physician licensed in the State of Washington
and I am'treating the above, patient for a terminal illness or a debilitating condition as defined by'
RCW 69.51A.010.
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I have advised the above named patient about the potential risks and benefits of the medical use
of marijuana, I have assessed tlleabi:Jve named patient's medicql histolY and medical condition.
It is my medical opinion that the potential~efits of the medical Lise of marijuana may outweigh
the [lealth risks for this patient. / / .'
Physician Name: Dr, Antoine J,chns/n WA License Number: MD00039048
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Physician Signature:
.1,"+---
1 Dale: 01/09/2009
This recommendation expires on: 72/05/2009' .
Risks and benefits of medical marijulna ' ,
Under Washington law, the use 0, medical marijuana IS now permiSSible for soma patients
with terminal or debilitating illnesses, The law regulating this (RCW 69.51A) allows physicians
to advise patients about the ris/