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Marijuana used medically may mitigate the symptoms or effects of this patient s condition. This is not a prescription for the use of medical marijuana. PHYSICIAN S SIGNATURE DATE MAIL ATTENDING PHYSICIAN S STATEMENT TO APS 2008 DHS/OMMP PO Box 14450 Portland OR 97293-0450. Print Form ATTENDING PHYSICIAN S STATEMENT Oregon Medical Marijuana Program Instructions Please complete all sections of this form in order to comply with the registration requirements of the Oregon Medical Marijuana Act OR provide relevant portions of the patient s medical record containing all information required on this form* This does not constitute a prescription for marijuana* If you need this document in an alternate format please call 971 673-1234 PLEASE TYPE OR PRINT LEGIBLY. A PATIENT INFORMATION PATIENT NAME LAST FIRST M. I. DATE OF BIRTH MAILING ADDRESS TELEPHONE CITY STATE AND ZIP CODE B PHYSICIAN INFORMATION PHYSICIAN NAME C PHYSICIAN S STATEMENT Debilitating Medical Condition Check appropriate boxes. 1. Malignant neoplasm Cancer 2. Glaucoma 3. Positive status for Human Immunodeficiency Virus HIV or Acquired Immune Deficiency Syndrome AIDS 4. Agitation due to Alzheimer s Disease 5. A medical condition or treatment for a medical condition that produces for a specific patient one or more of the following check all that apply a* Cachexia b. Severe pain c* Severe nausea d. Seizures including but not limited to seizures caused by epilepsy e. Persistent muscle spasms including but not limited to spasms caused by multiple sclerosis. Comments I hereby certify that I am a physician duly licensed to practice medicine in Oregon under ORS Chapter 677. I have primary responsibility for the care and treatment of the above-named patient. The above-named patient has been diagnosed with a debilitating medical condition as listed above. Print Form ATTENDING PHYSICIAN S STATEMENT Oregon Medical Marijuana Program Instructions Please complete all sections of this form in order to comply with the registration requirements of the Oregon Medical Marijuana Act OR provide relevant portions of the patient s medical record containing all information required on this form* This does not constitute a prescription for marijuana* If you need this document in an alternate format please call 971 673-1234 PLEASE TYPE OR PRINT LEGIBLY. A PATIENT INFORMATION PATIENT NAME LAST FIRST M. I. DATE OF BIRTH MAILING ADDRESS TELEPHONE CITY STATE AND ZIP CODE B PHYSICIAN INFORMATION PHYSICIAN NAME C PHYSICIAN S STATEMENT Debilitating Medical Condition Check appropriate boxes. A PATIENT INFORMATION PATIENT NAME LAST FIRST M. I. DATE OF BIRTH MAILING ADDRESS TELEPHONE CITY STATE AND ZIP CODE B PHYSICIAN INFORMATION PHYSICIAN NAME C PHYSICIAN S STATEMENT Debilitating Medical Condition Check appropriate boxes. 1. Malignant neoplasm Cancer 2. Glaucoma 3. Positive status for Human Immunodeficiency Virus HIV or Acquired Immune Deficiency Syndrome AIDS 4. 1. Malignant neoplasm Cancer 2. Glaucoma 3. Positive status for Human Immunodeficiency Virus HIV or Acquired Immune Deficiency Syndrome AIDS 4. Agitation due to Alzheimer s Disease 5. A medical condition or treatment for a medical condition that produces for a specific patient one or more of the following check all that apply a* Cachexia b.