I am being evaluated for a physician's recommendation for medicinal use of marijuana.  The physician will make this recommendation based, in part, on the medical information I have provided.  I have not misrepresented my medical condition in order to obtain this recommendation, and it is my intent to use marijuana only as needed for the treatment of my medical condition, not for recreational or non-medical purposes.  I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of marijuana.  I have been informed and understand the following items listed in this disclosure.

The federal government has classified marijuana as a Schedule I controlled substance.  Schedule I substances are defined, in part, as having (1) a high potential for abuse; (2) no currently accepted medical use in treatment in the United States,; and (3) a lack of accepted safety for use under medical supervision.  Federal law prohibits the manufacture, distribution, and possession of marijuana even in states, such as California, which have modified their state laws to treat marijuana as a medicine.

Marijuana has not been approved by the Food and Drug Administration for marketing as a drug.  Therefore the "manufacture" of marijuana for medical use is not subject to any standards, quality control, or other oversight.  Marijuana may contain unknown quantities of active ingredients (i.e., can vary in potency), impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.

The use of marijuana can affect coordination, motor skills, and cognition, i.e., the ability to think, judge, and reason.  While using marijuana, I should not drive, operate heavy machinery, or engage in any activities that require me to be alert and/or respond quickly.  I understand that if I drive while under the influence of marijuana, I can be arrested for "driving under the influence".

Potential side effects from the use of marijuana include, but are not limited to, the following:  dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory, euphoria, difficulty in completing complex tasks, suppression of the body's immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression, and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder.  In addition, the use of marijuana may cause me to talk or eat in excess, alter my perception of time and space, and impair my judgment.

I understand the using marijuana while under the influence of alcohol is not recommended.  Additional side effects may become present when using both alcohol and marijuana.

I agree to contact my physician if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells.  I will also contact my physician if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends.

The risks, benefits, and drug interactions of marijuana are not fully understood.  If I am taking medication or undergoing treatment for any medical condition, I understand that I should consult with my treating physician(s) before using marijuana and that I should not discontinue any medication or treatment previously prescribed unless advised to do so by the treating physician(s).

Individuals may develop a tolerance to, and/or dependence on, marijuana.  I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I should contact my physician.

Signs of withdrawal can include:  Feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances, and unusual tiredness.

Symptoms of marijuana overdose include, but are not limited to , nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation.  If I experience these symptoms, I agree to contact my physician or go to the nearest emergency room.

If Dr. Bojewski subsequently learns that the information I have furnished is false or misleading, the recommendation for marijuana may no longer be valid.

I have had the opportunity to discuss these matters with the physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified.  I acknowledge that Dr. Bojewski has informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana.  I acknowledge that Dr. Bojewski has informed me of the potential risk as well as benefit of medical marijuana and has offered no guarantee that it will successfully treat my condition. 

I will keep my medical marijuana card in my possession at all times.