Patient Consent Form Cannabinoid Therapy

Patient Details

Name(Required)
DD slash MM slash YYYY
Address(Required)

My St Francis doctor has proposed using a cannabis-based product to help improve my health profile. I understand:

  1. That the treatment is not guaranteed to work, as the scientific evidence of its effectiveness is limited.
  2. That I will be starting it as a trial, which we will stop or vary if there is not a significant benefit.
  3. That it may have some side effects, which my Medmate doctor and I have discussed.
  4. Using cannabis-based products in combination with alcohol is not recommended.
  5. That it may or may not lead to a reduction of my other medications.
  6. That the Medmate doctor will have to report on my progress to the Health Department.

I therefore agree:

  1. To take the treatment strictly as recommended and only alter the dose in discussion with my Medmate doctor.
  2. To report any beneficial effects and any side effects at the scheduled follow-up visits the Medmate doctor made for me.
  3. To be honest with the Medmate doctor about my full medical and psychiatric history, as well as any history of recreational drug use.
  4. Never to share the product with another person.
  5. Not to drive or operate machinery until the effects on my alertness have been assessed and discussed with the Medmate doctor.
  6. Driving laws prohibit driving with the presence of THC in the system.

Acknowledgement

MM slash DD slash YYYY
Name(Required)