Medical Marijuana Terms & Consent


I understand that I am entering into a bona fide physician-patient relationship with Dr. Cook, and that our relationship is not based on cannabis but on my symptoms and my need for care. I hereby declare that my primary intention with Dr. Cook is to receive care, whatever that may entail. I understand I am expected to return for occasional visits if the need arises, and that, if I am approved, medical cannabis certification is only a portion of my care. I understand Dr. Cook may not recommend medical cannabis, or may revoke his recommendation at any time.

I understand that I or my insurance carrier may be charged for general mental health care services which are distinct from medical cannabis applications or attestations. I understand that by providing my medical insurance information, I am doing so solely so that Dr. Cook may charge my insurance for general psychiatric services, not for medical cannabis services. I understand that Dr. Cook’s medical cannabis fee isn’t for the psychiatric assessment, but is a fee billed to me for professional time spent processing a 329 card application. I understand that I may not be approved for a 329 card for whatever reason medical or otherwise, and that any payment I make to Dr. Cook’s Office is final /non-refundable. I understand that the medical cannabis certification fee is set by Dr. Cook solely, is his prerogative, and isn’t covered by any insurance company. I understand a 329 card will expire after 12-24 months, and that re-certification fees are Dr. Cook’s prerogative, and, though they are subject to change, they may be equal or moderately less to my initial fee. I understand that there is no guarantee, once I have paid a fee, that I will receive a card within a certain timeframe. I accept unforeseen delays due to office volume or inaccuracies in paperwork.

I attest by signing below, that I am not on supervised probation or parole, or, if I am, that I have already received permission from my PO/judge that I may use medical cannabis (w/ doctor’s approval). I attest that I have no criminal history with regards to using medical cannabis, and that I have not been charged with a drug related crime, or had to complete a drug abuse treatment program, within two years… The potential side effects, risks, and benefits of medical cannabis use were discussed with me, and I consent. Risks include, but may not be limited to, chronic bronchitis, abnormal brain development among adolescents, impairment in short term memory, motor incoordination, and inability to perform complex psychomotor tasks such as driving, also: panic attacks, paranoia, and mild cognitive impairment. The likelihood of my improving without medical cannabis was discussed, as was reasonable treatment alternatives. No promise has been made as to a cure. I attest that the information provided by me, regarding my diagnosis and medical records, are true, and correct. I am requesting medical cannabis because I believe its medicinal uses will relieve my symptoms. I hereby declare that I have declared truthfully all medical information, and I am not visiting Dr. Cook in my capacity as a member, employee, or agent of any media, or law enforcement agency. I am aware that my approval or recommendation may be revoked at any time if I have perjured or misrepresented myself or my condition. I declare under penalty of perjury that the health information I have provided is true and correct… I understand that upon inquiry by a law enforcement agency, the Department of Public Safety will verify whether a particular qualifying patient has registered with the DOH, and may enjoy reasonable access to the cannabis registry, for law enforcement purposes. I understand Dr. Cook’s Office recommends my only visiting state licensed dispensaries and has no relationship with Care Waialua Farm or any other co-operative grow operations. I consent to be checked by Dr. Cook’s Office on Hawaii’s Prescription Drug Monitoring Program website. I understand that Dr. Cook’s Office makes no guarantees of immunity from cannabis laws, and the responsibility falls upon myself to research rules on the use and possession of medical cannabis. I understand if I am charged with a cannabis related crime, I have manifestly acted on my own behalf and Dr. Cook will not be involved… in this instance it is solely my responsibility to produce my 329 card. It is not Dr. Cook’s Office’s responsibility to demonstrate I have a 329 card. I understand if a letter giving proof of my certification is needed in the future, Dr. Cook’s Office will non-urgently provide a letter, addressed to ‘To Whom It May Concern’ , and may charge $50-$100 for the letter.

I understand that, should I be approved by Dr. Cook for a 329 card, by possessing such a card, that does not necessarily afford me job protection if my employer has enforced a drug-free workplace. I understand that if my building has a smoke/vapor free contract, I may be obligated, while at home, to use oils/tinctures instead. I understand that if I try to register a gun, HPD may block my gun registration, due to my having a 329 card. I attest that I do not drive large vehicles or operate heavy machinery for a living, and that, if I am approved, I will not drive a large vehicle or operate heavy machinery of any kind after using medical cannabis. If approved, I will only use medical cannabis in a responsible manner, in keeping with treatment of my illness. I attest that I am not pregnant, and that if I become pregnant, and am approved for medical cannabis, I will not use medical cannabis while pregnant, or nursing. Place: 1401 South Beretania Street, #450, Honolulu, HI 96826


Short PTSD Rating Interview (SPRINT)

COPYRIGHT ALL VERSIONS AND TRANSLATIONS OF THE SCALE © - Jonathan R.T. Davidson, 2000, 2011, 2013. All rights reserved. The scale may not be reproduced or transmitted in any form, or by any means, electronic or mechanical, including photocopying or information storage system, without permission in writing from Dr. Davidson, who can be contacted at mail@cd-risc.com.

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Document name: Medical Marijuana Terms & Consent
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