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No v. 26. 2008 4: 48PM CBR Medical Inc. : .. No. 2425 P. 3/5 ~- ••_0'·' .. ~~I-' " .....- _ of' .... ...fI' ~ 9 __,/~"",:,~..,;,:--..:... t. ..\)~ ~\ ..;_.~".. ,...... ~_ ."..,"' ~~ ___...._...... /,.r,,}."//,.I"):- Preeo~l"rint) . Proscriber's Si!1natu --___..L q"jj;(' -:-.---=--- License#: ... ~_ .... :-~ ~''''''J' .~"'\;i.~ .~••.. _.__. rJ!6ense ty~~:, ... j')_ ../.)-:::."-__--=__ Prescriber: please return this form ~nd the patient's Release 'of Information to: Medical DireCtor Health Services Division Washington state Del'iartmerit of Corrections PO Box 41123 Olympia; WA '981504-2113 ----.:. -~---..- ....._----.- To be filled oLit ~Y <strong>DOC</strong> Physician: . I I I I I i .......__.. "./' \",... /.... . '\ -'- "I"~ I VII',' "';I~. (" l.".~ .... ) -Iff'. ...,..:: )-.. .., • ;;- .. (0 •• J,) ",. "_~~:~_". I Phone 1'Iumber '
No'v, 26, 2008 4:48PM CB R Me d i ca 1 Inc, No, 2425 p, 4/5 Documentation of Medical Authorization to Possess M~rUlJana for Medical Purposes in Washington state PATIENTNAME: ______ DATEOFBIRTH:~ j I i ! I i , i· I, Antoine Joh!l~!l. __,___.., am a physician licensed in the State of Washington' and I am treating the above patient for a tetminaJ illn~$..ar·ajdebilitating condition as defined b¥ RCW 69.51A.010. . ./. J '. I have advised the above named patient about.tlie potentiaVrisks'and beMfits of the medical use of marijuana. I have assessed the above nartied patlent'sAnedical history and medical condition, It is my medical opinion that the potentiaU:5enefits of the rhedical use of marijl.lana may outweigh' the health risks f9r tfiis patient. Physician Name: _· __ .gL~n~oine..:.johnson i :.:.. :-" / WA License Number: __ Mtl00039048 ." ,.,.... " . ~#,." • Physician Signature: .: ..L.~" Daie: 08/24/2008 . . --"".;------ ~ ;:.=..:;.;;.;;.;;.;;-----;... This re·com.mendation eXPir~s on: _...QB/27;1!:~/-·-'-- I. Risks and benefits of medir-al marfiuanV :-" - . . Under Washington law, the US~Of edreal marijuana is now permissible for some patients with terminal or debilitating ilInesse " T1fe law regulating this (Rew 69.51A) allows physicians to advise patients C1Pout the risks nd qenefits of the medical use of marijuana, . The medical and scienlific e.lden~~ supporting the use of medical marijuana remains. controversial in the medical cytmnuOlty, Not 0111 health care prov(dets believe tllat medical marijuana is safe or effet:tivrand s.ome providers feel that it is a c1angerous drug. According to the WElshil)!lton State law the benefits of medical marij~lana may include treating nausea and vomiting from chemotherapy, AIDS wasting syndrome, severe muscle spasms from multiple scl¢rosis or other spasticity disorders, glaucoma, and some types of intractable pain. f" • . Some ·of the risks Of~llhedical marijuana may include possible long.:(erm effects of the brain .in the areas of memory, c orqiha\ion and cognition; impairment of the.. ability to drive or operm.te . heavy. machinery; respl ataTY damage; possible lung cancer; and physical or pE;ychologlcal dependence. '-:'. . Recommendation . As this patient's "60 day s~lpply", as stipulated by RCW 69,S'IA(2)(b), I recommend 24 ounces of dried, cured marijuana and as meny plants as the patient feels necessary to maintain this "60 day supply·. CBR Medical, Inc. Administrative Office 3115 E, Mission Ave Spokane, WA99202 Spokane: 509-242-8624 Seattle:. 206-774-6493 RevIsed 7/07 PDU-6655-3 000070·
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STATE OF WASHINGTON DEPARTMENT OF C
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RECORDS PROVIDED WITH REDACTIONS ~~
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i ( Documentation of Physician Auth
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Distefano, Monica J. (DOC) From: Se
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eRR Medical, Il1c 3115 E. Mission A
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Page 93 and 94: Interpretation of Medical Marijuana
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3115 E. Mission Ave Spokane, WA 992
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3115 E. Mission Ave 'Spokane, WA 99
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MARIJUANA MEDICINE- EVAlUATtON CENT
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· I, Karen Hamilton, am a physiCia
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Distefano, Monica J. (DOC) From: Ha
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OFFENDER 1.0. DATA: STATE OF WASHIN
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OFFENDER 1.0. DATA: STATE OFWASHING
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Scott L. Havsy, DO, DAApM -Board Ce
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I Prescriber's Name (Print) License
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