Name: [15] | Date of birth: [16] | Today’s Date: [17]

Part A: Must be completed for all medical marijuana patients

g. The current state of research on the efficacy of marijuana to treat the qualifying conditions set forth in this section.
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e. The potential side effects of medical marijuana use.
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f. The risks, benefits, and drug interactions of marijuana
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PART B: Certification for medical marijuana in a smokable marijuana for a patient under 18 with a diagnosed terminal condition.
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Part C: For certification of smoking marijuana as an appropriate route of administration for a qualified patient, other than a patient diagnosed with a terminal condition
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Part D: Must be completed for all medical marijuana patients
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[113] Dr. Wolpmann also informed me of the risks, complications, and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that Dr. Wolpmann informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits. Dr. has explained the information in this consent form about the medical use of marijuana.
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