DOC request three complete - Cannabis Defense Coalition

Dec.23. 2008 4: 49PM C B'R ·M.e die a 1 Inc. No. 2823 P. 2/28
OFFF.NCER ID. OATil:
STAT~ OF WASHINGTON
DEPARTMENT OF CORRECTIONS
Medicinal Use of Marijuan2 Verification
TO be filled out by Prescriber:
:,. __ ... 1~~ F"® __ I
Dear Prescriber, .
t:ly Stale staIUte me VV nntl;rt'Il"ln'll'lntr nr ritll.,tinnr th..,t lQ'l1ri In thi-ir f'rimin'iill·
behavior. Often illicit drug use is a contributing factor in an individual's criminality. Accordingly it's usual that the court"or
the ·Department of Corrections will impose a condition of supervision that the offender not use. or possess illicit drugs,
including marijuana. This offender has .claimed that they nave a condition for which the medicinal use of marijuaria has
been recommended: The below verification is to determine the legitimacy of their Claim. Thank you in advi;lnce for your
l.
725-8700. . . ~'
1. Is this pati~n~ under your care Q Yes D No
~. p.re you reCOlllrrll:lIIlJIIIY IIIt:I./fI,:CllllldiljudIlCirul !rio !o'",lic,·.LdLc6 t.::." dingl'l~:5i~ ofAoql.1!rod
Immunodeficiency Syndrome (AIDS)
a. If the answer to' question 2 is "Yes", does he/she have anorexia r-tlf~
b. . If the answer to question ~a is .IIYes". does' he/she have w!;liylrllu~~tl/.r.;·
3. Are you recommending medical marijuana for this patient due to nausea and vomiting
associated with cancer chemotherapy
UYes
[3~-nNO
Q.¥-e9'-~·"·B .. No
DYes
a. If the answer to question 3 is "Yes", has the patlent failed to respond to conventional
antiemetic treatments #/A-. .. . .
!
b. If thf'l AnRWAr to !1u('::;;tion 3a is ·YeS". pl~ase describe what those treatments were (medication, dose, .
duration): .. . ,if A- . .'. .
c. What is the Plan~ed .schedule of chemotherapy IV I Pr
~.
. .
4.
. I:J.
6.
a.' .
If y~~ ans~ered "No" to items 2 &. ~~. bove, whatis th~ reason you are recommending medicinal u~e of
marIjuana.· ,,~ e .
'" ~ . ~ "h.t ~ .
. . '- "- • or-..... ~. • .c;... .
t'l~Cl::,t:: fJ1\,JVIUC CYIUt;;I,'¥t;:i tJULJ"""II""'" J. l ..... !'IV~' 1_.1_ •• :... .... __ :_ •. cri_ r ... 1.1" .•• : ... 10 ... _ •• ,.. ....... fh,.. n'l1'IaI'Iir'\innll rrn "f
marijuana. for this purpose ( ~. . \ • (\ .' .
r
j~-~.
~c;.,.",~-~
YYT1JI6 on COmfflI,JIIIlY :101.11-'1;:1 Vh:lIUIl \ ).I", ..... '" J L"'" ...... J-' .. d", ..... ~ -P "'--: •• _..:~t_ .. _. ':"', ..• ~. ~-1-7- " ...
use ofthe oral synthetic formulation of marijuana. lfthe Department authorizes thiS patlent·s . 0 Yes
use of medical marijuana. will you be prescribing only the oral synthetic fcrmul.ation
The patient's accompanying Releas~ Of Info.rmation authOfi
7es you to provide the . .
Department with current and future mformatton related to thIS Issue. Do you agree. to notify
rhn nnn'irtmQnt'li Mli'lriiral nifFr.tnr of nnv r.himQ~~ in Y9ur answers above
DYes
/
[No·
UOG 14·053 (Rev. 7131/06)
DOC 380.200
PDU-6655-3000456