Thank you for your interest in Medical Cannabis! 

This form is FREE to complete and is HIPPA compliant

Medical Cannabis Appointment is a total cost of $400.

A $100 deposit will be required PRIOR to scheduling.

Submit this application and our office will call/text you to schedule

MEDICAL CANNABIS INFORMATION 

 

Be Honest!

This form is private and will only be accessed by our 5 team-members.

Your knowledge level and what you have/haven't tried in the past will help us  schedule the appropriate amount of time for each patient. 

 

PAST MEDICAL HISTORY 

 

Office Policies

• Payments for services are due when services are rendered. No insurance companies in Utah are covering Medical Cannabis Evaluations.
• Dr. Anden and staff are dedicated to providing you with the best possible care and services. We have adopted the following financial policies in order to minimize confusion or misunderstanding between our patients and practice.
• I understand the attending physician, staff and or representatives of Dr. Anden are neither providing or dispensing medical cannabis products.
• Dr. Anden and her staff are addressing specific medical cananbis related aspects of my medical care and are in no way establishing themselves as my primary care physician/provider. 
• Furthermore anyone acting on behalf, holds the physician and her principals, agents and employees, free of and harmless from any responsibility for any harm resulting to me and/or other individuals as a result of my medical marijuana use.

Patient Acknowledgement

• I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition and attest that I do not intend to use my medical recommendation for the purpose of illegally obtaining, growing or distributing medical marijuana.
• I am aware that my recommendation can be revoked at any time and legal actions will be taken if I have perjured or misrepresented myself or my condition, my intentions or falsified any medical records to the physician.
• Additionally, I acknowledge the attending physician informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana. The risks, complications and expected benefits of any recommended treatment, including its likelihood of success or failure.

Notice of Privacy Practice (Receive a copy in our office on your appt day!)

• I have been offerd the practice’s Notice of Privacy Practices. The Notice provides in detail the uses and disclosures of my PHI (Protected Health Information) that may be made by this practice. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all PHI at, or controlled by, this practice. I understand I can obtain this practice’s Notice of Privacy on request.
• Authorization for Use/Disclose of Protected Health Information (PHI)
  I authorize the use and disclosure of all health information for the purpose of treatment, payment and Health Care Operations. I authorize Dr. Anden and staff to use these disclosures of my health information without limitation. I understand that information disclosed pursuant to this authorization may be re-disclosed to additional parties and no longer protected. I understand that any revocation does not apply to disclosures or use of PHI that have occurred prior to my revocation.

I have read and fully understand the policies of this office regarding:

1. Payment and Insurance
2. Patient Acknowledgement
3. Notice of Privacy Practice

 

Medical Marijuana Patient Declaration

• I understand that medical marijuana is a medicine used in treating the suffering caused by serious and debilitating medical conditions.
• I have been advised that the use of medical marijuana may affect my coordination, motor skills and cognition in ways that could impair my ability to drive and agree not to operate heavy machinery, drive or engage in potentially hazardous activities.
• I understand that side effects may occur while I am taking medical marijuana. Side effects of medical marijuana may include but are not limited to: euphoria, difficulty in completing complex tasks, low blood pressure, sedation, dysphoria, alterations in the perception of time and space, dizziness, anxiety, confusion, impairment to short term memory, inability to concentrate,  increased talkativeness, impairment of motor skills, delayed reaction time, loss of physical coordination, paranoia, and increased eating.
• I understand that chronic use of medical marijuana may lead to laryngitis, bronchitis and general apathy.
• I understand that although marijuana does not produce a specific psychosis, it may exacerbate schizophrenia in persons predisposed to that disorder.
• I understand there are few known interactions between marijuana and medications other than herbs. However, very few interactions between herbs and medications have been studied. I agree to tell my attending physician if I am using any herbs, supplements or other medications.
• I am aware that a Notice of Compliance has not been issued under the Food and Drug Regulations concerning the safety and effectiveness of Marijuana as a drug. I understand the significance of this fact.
• I am aware that medical marijuana has not been approved under Federal Regulations and I understand that medical marijuana has not been deemed legal under federal law.
• I understand the benefits and risks associated with the use of marijuana are not fully understood and that the use of marijuana may involve risks that have not been identified. I accept such risk.
• I have been advised that medical marijuana smoke contain chemicals known as tars that may be harmful to my health. I understand that there are many methods of intake that substantially reduce the harmful effects of smoking such as vaporizers, edibles, tinctures, etc.
• If I am a Female - I agree to contact my attending physician if I become or are thinking about becoming pregnant. I acknowledge that the use of medical marijuana creates pass-through problems to a fetus during pregnancy and to a baby during breastfeeding.
• I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.
• I understand that I should not be driving a vehicle while using marijuana and that I can get a DUI for driving under the influence.
• Medical marijuana is not regulated by the USFDA and therefore may contain unknown quantities of active ingredients, impurities and or contaminants.
• I am not permitted to smoke within 1,000 feet of any daycare or school. If I reside near those institutions, I must use my medicine within the privacy of my own home.
• I agree to follow up with the attending physician with supporting medical records pertaining to my medical conditions.

 

 

No-Show Policy

 

 A $100 deposit is required to schedule.

If you no-show your appointment, the deposit wil be kept.

If you are more than 15 minutes late, this will be considered a no-show and your deposit will be forfitted. 

 

 

You are all done!

Please push Submit to send us your application.

A $100 deposit is required to schedule.  After you push "Submit" you will be re-routed to our payment section. 

Our team will contact you AFTER you've paid the $100 deposit.

The remaining $300 will be collected at your appointment.

 

Thank You!