Follow-Up Cannabis MD Assessment
Please complete for your 4th visit or any monthly or yearly follow up assessment. Please read: ALL WILL TAKE PLACE ONLINE. YOU WILL RECEIVE A PRIVATE LINK IN YOUR EMAIL. Your privacy and security is important to us. We are using tele-medicine for ease and convenience, please be aware there are some risks but we have invested in secure platforms. By using this form, you consent to treatment by Smart Cannabis MD physicians. I also agree to pay any cost associated with any clinical visits. The fees are listed on our website.
If you are under 18 or have help filling out the form, please write the person filling out the form's name and relationship to the Patient.
Patient Name (First and Last as it appears on your form of ID)
Thank you for choosing to continue care with Smart Cannabis MD. Privacy and security are important to us. These forms uphold HIPAA rules. I understand that the state of NJ has set forth rules and standards for the Medicinal Marijuana Program (MMP). A fourth visit is required. A minimum of yearly visits are required. Our fees are listed on our website. I understand the side effects are sedation and disruption of sleep, dry mouth, nausea, vomiting, dry eyes, heart and blood pressure issues, lung problems, impaired mental functioning, headache, dizziness, numbness, panic reactions, hallucinations flashbacks, depression, anxiety, mood disorders, sexual problems, suicidality, psychosis, hallucinations, weight gain, gynecomastia, addiction and dependence (
DOH MMP). I understand that this is my choice to take part in this program. I consent to treatment. By typing my name it means that I understand and agree.
Check your MMP Qualifying condition (s)
Chronic Pain (pain greater than 4-6 weeks in the same region)
Intractable Muscular Spasticity
PTSD (post traumatic stress disorder)
Dysmenorrhea (painful cramps)
Inflammatory Bowel Disease (Crohn's or Ulcerative Colitis ONLY - IBS with pain would go under chronic pain)
Cancer with Pain, Nausea/Vomiting, Terminal Nature
Opioid Abuse Disorder (currently under treatment)
HIV/AIDS related issue
Terminal Condition (Death may be expected in the next 6 to 12 months)
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