WE ARE NOW OFFERING MEDICAL MARIJUANA. A patient can be certified to use medical marijuana if they suffer from:

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Transcription:

WE ARE NOW OFFERING MEDICAL MARIJUANA A patient can be certified to use medical marijuana if they suffer from: Epilepsy / Seizures Parkinson Disease Multiple Sclerosis (MS) Post-Traumatic Stress Disorder (PTSD) Amyotrophic Lateral Sclerosis (ALS) Glaucoma HIV/AIDS Cancer Crohn Disease Chronic Nonmalignant Pain from a condition listed above A Terminal Condition Medical Conditions of the same kind or comparable to those above These may include: Chronic Pain Headache Migraine Stress Anxiety Muscle Spasms Insomnia Fibromyalgia Rheumatoid Arthritis Frequent Urination How to become certified to use medical marijuana: Schedule an appointment with a certified physician. If you qualify you will be issued a certification. Once you have applied for and been approved for your Medical Marijuana Use Registry ID Card (https://mmuregistry.flhealth.gov), your physician will place an order for Low-THC (CBD) and/or Medical Marijuana products. Obtain Medical Marijuana products from any dispensary.

Volusia Natural Wellness Jeffrey S Corak, MD 760 S Volusia Ave, Suite 400 Orange City, FL 32763 Tel (386) 774-0308 Fax (386) 774-0961 www.volusianeurology.com/medicalmarijuana Dear Patient: You have an appointment scheduled with Dr Jeffrey Corak. We have enclosed patient information forms to be completed and brought to your appointment. Please also bring all medications, pertinent medical records and test results. If the diagnosis for which you are requesting Medical Marijuana has already been made by another physician please bring appropriate documentation. Please allow one week for initial certification. You will then be contacted via email or phone with the information necessary to register online (https://mmuregistry.flhealth.gov) or by mail with the state. They will send you your ID number within several days which can be used to obtain product from a dispensary even before receiving your ID card which may take up to two weeks. Initial certification is good for 210 days after which you will need to be reevaluated and recertified. Prescriptions are made online and are valid for 70 days. Certification includes two 70-day refills. The charge for initial certification is $250 and for each recertification $195. If you need to be seen before a recertification the charge is $49. Payment will be due at the time of service. Should you need to contact us, our office hours are Monday to Friday, 9 am to 5 pm. Messages left for the nurse will be returned within 24 hours. We also kindly request that you refrain from wearing perfume, cologne or scented lotions in the office. Should you need to cancel your appointment, please contact our office 24 hours in advance or you will be subject to a missed appointment fee. We make every effort to be on time and ask that you do the same, but your appointment could be delayed. We ask for your understanding should this occur. Please feel free to contact our office with any questions or concerns.

Volusia Natural Wellness Jeffrey S Corak, MD 760 S Volusia Ave, Suite 400 Orange City, FL 32763 Tel (386) 774-0308 Fax (386) 774-0961 www.volusianeurology.com/medicalmarijuana PATIENT INFORMATION SHEET Date: 20 Last Name: Home Phone: ( ) First Name: Middle Initial: Work Phone: ( ) Address: Cell Phone: ( ) City: State: Zip: Email: DOB: Age: SSN: Employer: Address: Phone: ( ) Pharmacy Name: Phone: ( ) Family Doctor: Phone: ( ) In An Emergency Notify: Phone: ( ) If Patient Is A Minor, Parent s Name: Please Complete This Form And The Attached Medical Questionnaires And Bring With You To The Office For Your Appointment On: At: Office Fees Are Due At The Time Of Service

At Volusia Natural Wellness your well being is our primary concern. In order to offer you the best treatment possible please complete this form as accurately and completely as you can. Name: Age: Weight: Please describe the diseases or symptoms you wish to treat with Medical Marijuana (including other doctors seen, tests done and treatments tried): Do you suffer from: Back Pain Neck Pain Headaches / Migraine Burning Feet Muscle Spasms Frequent Urination Leg Pain Arm / Hand Pain Facial Pain Joint Pain Insomnia Stress / Anxiety List your other medical problems (e.g., High Blood Pressure, Diabetes):

Have you ever had cancer? What kind? List any operations you have had, including dates: List all medications you are currently taking, including dosages: List any medications you are allergic to: Do you smoke? If yes, how much: Do you drink alcohol? If yes, how much: Marital status: Number and ages of children: What type of work do you (or did you) do: Are there others in your family with the same problem as you? List any medical problems in your mother: siblings: father: children:

Volusia Natural Wellness Jeffrey S Corak, MD 760 S Volusia Ave, Suite 400 Orange City, FL 32763 Tel (386) 774-0308 Fax (386) 774-0961 www.volusianeurology.com/medicalmarijuana Acknowledgement of Privacy Practices Our notice of Privacy Practices provides information about how we may use and release protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by writing our practice or requesting a copy from our front desk staff. You have the right to request that we restrict how protected health information about you is used or released for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and release of protected health information about you for treatment, payment and health care operations as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made releases in reliance on your prior consent. We may refuse to treat you if you do not sign this Consent Form or sign this Consent Form and then revoke it. I acknowledge and agree that my protected health information and medical record information may be disclosed to the following individuals: Name: Relationship: I have read and understand the information in this consent. Patient Name (print): Patient Signature: Date: Witness:

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