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Get CA CDPH 9044 2009-2024

A copy of this form must be filed in the attending physician s medical records for the patient. If the patient chooses to apply for a Medical Marijuana Identification card through the county health department or its designee the agency will call the attending physician to verify the information contained on this form in accordance with Health Safety Code Section11362. 72 a 3. California medical license number Service mailing address number street Office telephone number City State ZIP code Office fax number Licensed by check one Medical Board of California Osteopathic Medical Board of California is a patient under the medical care and supervision of the above Patient s name named physician who has diagnosed the patient with one or more of the following medical conditions Acquired Immune Deficiency Syndrome AIDS Anorexia Arthritis Cachexia Cancer Chronic pain Glaucoma Migraine Persistent muscle spasms including but not limited to spasms associated with multiple sclerosis Seizures including but not limited to seizures associated with epilepsy Severe nausea Any other chronic or persistent medical symptom that either a. Substantially limits the ability of the person to conduct one or more major life activities as defined in the Americans with Disabilities Act of 1990. b. If not alleviated may cause serious harm to the patient s safety or physical or mental health ATTENDING PHYSICIAN STATEMENT This patient has been diagnosed with one or more of the foregoing medical conditions and the use of medical Telephone number Original Patient CDPH 9044 1/09 Copy Patient s File Date. State of California Health and Human Services Agency California Department of Public Health Medical Marijuana Program WRITTEN DOCUMENTATION OF PATIENT S MEDICAL RECORDS Please Print Note to Attending Physician This is not a mandatory form* If used this form will serve as written documentation from the attending physician stating that the patient has been diagnosed with a serious medical condition and that the medical use of marijuana is appropriate. A copy of this form must be filed in the attending physician s medical records for the patient. If the patient chooses to apply for a Medical Marijuana Identification card through the county health department or its designee the agency will call the attending physician to verify the information contained on this form in accordance with Health Safety Code Section11362. 72 a 3. California medical license number Service mailing address number street Office telephone number City State ZIP code Office fax number Licensed by check one Medical Board of California Osteopathic Medical Board of California is a patient under the medical care and supervision of the above Patient s name named physician who has diagnosed the patient with one or more of the following medical conditions Acquired Immune Deficiency Syndrome AIDS Anorexia Arthritis Cachexia Cancer Chronic pain Glaucoma Migraine Persistent muscle spasms including but not limited to spasms associated with multiple sclerosis Seizures including but not limited to seizures associated with epilepsy Severe nausea Any other chronic or persistent medical symptom that either a* Substantially limits the ability of the person to conduct one or more major life activities as defined in the Americans with Disabilities Act of 1990. .

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