is a patient under my medical care for

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(Print Diagnosis)

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(ICD-9 Codes)


My patient and I have discussed the use of medical marijuana/cannabis as therapy for the patient's condition. My patient understands the benefits, risks and possible side effects commonly associated with this therapy.

I recommend/approve of my patient's use of medical marijuana/cannabis as therapy for this condition. This document is intended only to provide information required to establish eligibility for my patient's use of medical marijuana/cannabis compliant with the "Compassionate Use Act of 1996."

Approval Period_______3 Months_______6 Months

Other Instructions

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Physician's Signature

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Physician's Printed Name

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California Physician's License Number

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Street Address

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City State Zip

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Telephone Number