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Medical Marijuana Evaluation
Intake Form
First Name:________________________________ MI:___ Last Name:__________________________________
Address:_____________________________________City:_________________________Zip Code____________
Home Phone:_______________________ Cell Phone:______________________ Date of Birth: ______________
Email Address:_______________________________ MI. Drivers Lic./ID#:_______________________________
Preferred method of contact: Email
Cell Phone
Home Phone
Mail
Other_______________________
1. How did you hear about this clinic?______________________________________________________________________
2. Do you currently have a Michigan Medical Marijuana Card?
Yes
No
I did but it has expired
3. The doctor you saw for your previous medical marijuana evaluation:____________________________________________
4. What symptoms do you hope that medical marijuana will help you with:_________________________________________
5. Have you been diagnosed with any of the following medical conditions: Hepatitis C HIV or Aids Glaucoma Crohns
Disease Agitation of Alzheimers Disease Nail Patella ALS
Cancer (type/location)____________________________
6. Have you been diagnosed with a disease or condition that produces any of the following: ( Severe Nausea
Cachexia/Wasting Syndrome
Severe and Chronic Pain
Severe and Persistent Muscle Spasms
Seizures
(List the condition below)
Disease/condition that causes the above: _____________________________________________________________
7. When did this condition/problem start:___________________________________________________________________
8. Last time you visited the doctor about this condition:________________________________________________________
9. Treatments that you have tried/are trying for this condition:___________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
10. Medications you are currently taking:____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
11. Previous related surgeries:_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Women:
12. Are you pregnant?
Yes
No
Unsure
13. Do you plan to become pregnant in the next 2 years?
Yes
No
N/A ___________________________________
14. Would you like us to send a copy of your office visit note to your PCP or other provider?
Yes
No
If yes, Providers Name:______________________________Address:__________________________________________
Page 1
Medical Marijuana Information
Name_______________________________ Birthdate:______________________
Instructions: Read each of the statements below and sign at the bottom of this page acknowledging that you
understand each statement. If you have a question or do not understand any of the statements, please ask Dr.
Townsend to clarify during your evaluation.
I understand that medical marijuana is used to aid in the suffering of serious and debilitating medical conditions. The qualifying
conditions under the Michigan Medical Marijuana Act are Cancer, HIV/AIDS, Hepatitis C, Glaucoma, Crohns Disease, ALS, Nail
Patella and Agitation of Alzheimers Disease OR A condition or disease that produces one of the following: severe and chronic pain,
severe nausea, seizures, severe and persistent muscle spasms, or cachexia/wasting syndrome.
Marijuana is a Schedule 1 narcotic and is not regulated by the FDA. Scientific study data on marijuana as a medication is not widely
available, although it has been reported to be useful in several serious, debilitating conditions. I understand that the benefits and risks
associated with the use of marijuana are not fully understood and that its use may involve risks that have not yet been identified.
Known side effects of marijuana may include dry mouth, increased appetite, sleepiness, short term memory impairment and
inattention. There have been no known overdoses or deaths reported.
Smoking ANYTHING including marijuana can cause respiratory issues. Using a vaporizer may substantially reduce many of the
risks associated with smoking.
The possibility exists that marijuana may exacerbate symptoms in patients diagnosed with schizophrenia. .
The use of marijuana may affect your coordination and cognition in ways that could impair your ability to drive. You should not
operate heavy machinery, drive or engage in potentially hazardous activities while under the influence of marijuana.
The cultivation, possession and use of marijuana, even for medical purposes is still illegal under federal law. Dr. Townsend/Denali
Healthcare is neither dispensing, providing or encouraging you to obtain medical marijuana.
You understand that marijuana use is not recomended during pregnancy. If you become pregnant and test positive for marijuana
during pregnancy or delivery you are at risk of having Child Protective Services being notified by the testing healthcare provider.
You understand that medical marijuana is not a substitute for standard medical treatment in any serious, potentially life threatening
health condition. Do not stop any prescribed medications without consulting your PCP/prescribing physician beforehand.
Dr. Townsend recommends that all patients follow up with him on a regular basis to further solidify the “Dr-Pt Bonafide
Relationship” as defined by the State of Michigan. Scheduling a follow up appointment can be done during your initial evaluation or
by calling the office. Follow up visits pertaining to your medical marijuana certification and qualifying condition are included in
your initial evaluation fee for 2 years.
Many factors should be considered in a patients dosing of medical marijuana including quality/potency of marijuana, strain/type
utilized, health conditions and patients tolerance to marijuana. Most patients can control there symptoms with less than an ounce of
medical marijuana weekly.
You understand that in the event your qualifying condition or symptoms fully resolve, you must discontinue your usage of medical
marijuana and notify both LARA and our office.
By signing below, I acknowledge that I have read and understood each of the above statements. A copy
of this document was available during my initial appointment. I am aware that I can receive a copy of
this document at anytime by visiting www.denalihealthcaremi.com or by calling Denali Healthcare.
Patient Signature______________________________________________________ Date:________________________
Page 2
MMP 3501 A(Rev. 12/13)
Michigan Medical Marihuana Program
Application Instructions and Checklist
(517)373-0395 | www.michigan.gov/mmp
Instructions for applying to the Michigan Medical Marihuana Program
Instructions
1. Mail only one complete application and all required documentation (see below) in one envelope to:
Michigan Medical Marihuana Program
PO Box 30083
Lansing, MI 48909
2.
3.
4.
5.
Make checks or money orders payable to: State of Michigan-MMMP
This application is for a person who is 18 years of age or older and a resident of Michigan.
Please type or print legibly when completing the application.
The original signed Application Form and Physician Certification Form must be submitted to the MMMP.
Make sure to keep a copy of the completed Application and Physician Certification Form for your records.
Checklist
 Application Form for Registry Identification Card
 Any use of white-out on or alterations to the Application Form will result in the denial of your application.
 If you are acting as either the legal guardian or Medical Durable Power of Attorney (MDPOA) for
the applicant, you must submit a copy of proof of legal guardianship or MDPOA with signatory authority
with the application. The MDPOA or legal guardian must also submit a copy of their valid photo ID (see
copy of valid photo ID below).
 Application Fee: $100
 A patient who currently receives full Medicaid benefits or Supplemental Security Income (SSI) and
submits the appropriate supporting documentation is eligible for a reduced registration fee. The
reduced registration fee is $25.00. Examples of acceptable supporting documentation are available on our
website at: www.michigan.gov/mmp.
 Copy of Valid Photo ID (Michigan Driver’s license, Michigan ID card, or other acceptable form of ID)
 The copy of the photo ID must be clear and legible.
 If you are designating a caregiver, you must also submit a copy of your caregiver’s valid photo ID
(Michigan driver’s license or Michigan ID card or other acceptable form of identification).
 If you submit a copy of a photo ID that is not a Michigan driver’s license or Michigan ID card, you must also
submit a copy of your Michigan voter’s registration card as proof of residency.
 Physician Certification Form
 A complete Physician Certification Form must be completed and signed by a Medical Doctor or Doctor of
Osteopathic Medicine and Surgery who is fully licensed by the State of Michigan.
 Any use of white-out on or alterations to the Physician Certification Form will result in the denial of your
application.
Page 1 of 3
For Official Use Only
MMP 3501 (Rev. 12/13)
www.michigan.gov/mmp
(517)373-0395
Michigan Medical Marihuana Program
Application Form for Registry Identification Card
Section A: Patient Information (REQUIRED)
1. Legal First Name
2. Middle Initial
4. Patient Registry ID Card Number (For Renewals Only)
3a. Legal Last Name
3b. Suffix (Jr., Sr., III, etc.)
5. MI Driver’s License# or MI ID Card #
6. Date of Birth (MM/DD/YYYY)
P
7a. Mailing Address
7b. Apartment/Suite/Lot #
8. City
9. State
10. Zip Code
MI
11. Email Address (If provided, you agree to receive email correspondence from MMMP)
12. Telephone Number
Section B: Person Allowed to Possess Patient’s Marihuana Plants: (REQUIRED)
13. Plant possession: You must select one box. Failure to do so will result in the denial of your application.
SELECT ONLY ONE:
☒
I will possess the plants
☒
My caregiver will possess the plants
Section C: Caregiver Information (If the patient is designating a caregiver)
14. Legal First Name
15. Middle Initial
16a. Legal Last Name
16b. Suffix (Jr., Sr., III, etc.)
17. Caregiver Registry Card ID Number (For Renewals Only) 18. MI Driver’s License# or MI ID Card # 19. Date of Birth (MM/DD/YYYY)
C
20a. Mailing Address
20b. Apartment/Suite/Lot #
21. City
22. State 23. Zip Code
MI
24. Email Address (If provided, you agree to receive email correspondence from MMMP)
25. Telephone Number
26. Other Names Used by Caregiver (Nick names, maiden names etc. Use a separate piece of paper if you need space for additional names)
Section D: Patient Signature & Date (Required)
By signing below, I attest that the information entered on this application is true and accurate. I am aware that a false or dishonest answer may be
grounds for the denial or nullification of my registration and such misrepresentation is punishable by law. I attest that I have designated the person
listed in Section C to serve as my caregiver (if a person is listed). I understand that I am required to know and comply with the requirements of the
Michigan Medical Marihuana Act, Administrative Rules, and all amendments.
Signature of Applicant/Patient: X
Section E: Caregiver Attestation: (Required if the patient is designating a caregiver)
Date: _____________________
By signing below, I attest that the information entered on this application is true and accurate. I am aware that a false or dishonest answer may be
grounds for the denial or nullification of my registration and such misrepresentation is punishable by law. I understand that I am required to know
and comply with the Michigan Medical Marihuana Act, Administrative Rules, and all amendments. I authorize this agency to use the information I
have provided to obtain a criminal conviction history file search from the Central Records Division of the Michigan Department of State Police or
other law enforcement or judicial recordkeeping organization to determine if I have been convicted of any of the felony offenses that would make
me ineligible to be a caregiver. I declare that I am willing and able to serve as the caregiver for the patient listed in Section A.
Signature of Caregiver:
X
Date: _____________________
Page 2 of 3
MMP 3020 (Rev. 12/13)
Michigan Medical Marihuana Program
Physician Certification Form
(517)373-0395 | www.michigan.gov/mmp
This certification must be completed and signed by a Medical Doctor or Doctor of Osteopathic Medicine and Surgery who is fully licensed by the State of Michigan
Section A: Certifying Physician Information (Required)
1. Legal First Name
2. Middle Initial
3a. Legal Last Name
Robert
L.
Townsend
4a. Full Mailing Address
437 S. Mission St.
4b. Apartment/Suite/Lot #
5. City
6. State
7. Zip Code
Mt. Pleasant
MI
48858
9. Michigan Physician License Number
8. Telephone Number
( 989 ) 339-4464
2 ___
9 ___
6
1 ___
6 ___
0 ___
D.O. 5101 ___
M.D. 4301 ___ ___ ___ ___ ___ ___
Section B: Patient Information (Required)
10. Legal First Name
3b. Suffix (Jr., Sr., III, etc.)
11. Middle Initial
12a. Legal Last Name
12b. Suffix (Jr., Sr., III, etc.)
13. Date of Birth
Section C: Patient’s Debilitating Medical Condition(s) (Required)
This patient has been diagnosed with the following debilitating medical condition:
(A minimum of one box must be checked in at least one of the following categories.)
Category A
Category B
Category C
A chronic or debilitating disease or
Check
and list a condition which has been
 Cancer
medical condition or its treatment that
approved by the Medical Marihuana
 Glaucoma
produces 1 or more of the following:
Review Panel:
 HIV Positive or AIDS
 Cachexia or Wasting Syndrome
 Approved medical condition:
 Hepatitis C
 Severe and Chronic Pain
______________________________
 Amyotrophic Lateral Sclerosis
 Severe Nausea
______________________________
 Crohn’s Disease
 Seizures (Including but not limited to
______________________________
 Agitation of Alzheimer’s Disease
those characteristic of Epilepsy.)
 Nail Patella
 Severe and Persistent Muscle Spasms
______________________________
(Including but not limited to those
______________________________
characteristic of Multiple Sclerosis.)
Section D: Certification, Signature and Date (Required)
By signing below, I attest that the information entered on this certification is true and accurate. I attest that I am in compliance with the
Michigan Medical Marihuana Act, Administrative Rules, and all amendments. I attest that I have completed a full assessment of the
patient’s medical history and current medical condition, including a relevant, in-person, medical evaluation. Further, I attest that in my
professional opinion, the patient is likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate
the patient’s debilitating medical condition or symptoms associated with the debilitating medical condition.
Signature of Physician: X
Date: _____________________
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