blank physician’s statement recommending medical cannabis

Physician’s Statement
Regarding Medical Cannabis
as per California Health & Safety Code 11362.5

To Whom It May Concern:

this statement certifies that

___________________________________________
(patient)

is a patient uncer my care and supervision for the treatment of

___________________________________________
(diagnosis)

____ (optional; please check if applicable) I decline to state my patient’s diagnosis to protect his or her confidentiality

I have discussed the benefits and risks of cannabis use with my patient as a treatment for his or her condition. I recommend or approve cannabis use for my patient. If my patient chooses to use cannabis therapeutically, I will continue to monitor his or her condition and provide feedback on his or her progress.

I understand that I will be contacted to verify the content of this letter. My patient authorizes me to discuss this recommendation or approval for verification purposes only.

I am a physician licensed to practice medicine in California.

This statement is valid until

___________________________________________
expiration date

___________________________________________
physician’s signature

___________________________________________
physician’s name (please print)

___________________________________________
physician’s CA license no.

___________________________________________
date of recommendation

___________________________________________
physician’s address 1

___________________________________________
physician’s address 2

___________________________________________
city, state, zip

___________________________________________
physician’s telephone


this letter is a confidential medical statement