DOC request three complete - Cannabis Defense Coalition

Jan, 14, 2009 9:53PM CBR Medical Inc, No,3105 .p, 3
OFFF.NDClUI.l. OA'rA:
STATE OF WASHINGTON
DEPARilVlENT OF CORRECTIONS
Medicinal Use of Marijuana Verification
. .
To be out
r patien~j.S .. Name.
TD be filled out by Prescriber:
Dear Prescriber,
By state statute the Washington State Department of Corrections is charged with the responsibfiity to supervise some
offenders after they have been conVicted of a felony. The above named patient is currently under supervision by the
Departrnent Supervision is designed to help the offender avoid those environments or situations that lead to their criminal
behavior'. Often illicit drug use 15 a contributing f f1F'nFlrtmp.nt Of ~0r.rections onlr authorizes the'
Use ofthe oral syntnel:rc Tormutatlon ojmalIJ'l;tdl~a, 1('/""C'\!J~p6I'(,\ w,,' -:... ~ ,-,.- - :-.. , ,...,
use of medical ~arijuana, will you be prescribing only tile oral synthetic f-ormulation
/,'
6.
The patient's accompanying Release of Information autllorize~ yau to provide.the .
Department with current and future information related to this Issue. 00 you agree to notIfy
the Department's Medica! Director of any changes in your answers above
DYes
~ (Rev. 1/31/08)
DOC3B0200
PDU-6655-3 000346