Here at D.O. IT Medical Evaluations, we are firm believers in the healing properties and the safety of cannabis when compared to other medications. We both, realize the many potential uses of cannabis and understand that you may find relief for many ailments or conditions through the use of cannabis. However, please be aware, that certification for a Red Card through the state of Colorado is only possible for APPROVED conditions.

Understanding that obtaining a Medical Cannabis card is more than just paying a fee or joining a club so you can get cheaper or stronger cannabis is crucial. In order to obtain a medical cannabis card, you must actually have the condition you are claiming to have, and you may be asked to provide medical records verifying your claim. If medical records cannot be produced, you may be denied. If your 25 years old or younger, medical records are required by our clinic. If you are under 21 years old, parent presence and approval is also required as well.

Please be sure you want to be seen before you pay. If you are seen by the doctor and denied a card, you will be issued a PARTIAL refund. (A $20.00  fee for the doctor’s time will be assessed We apologize for any inconvenience, but we must abide by the law.

By signing below attest that I have a debilitating medical condition as defined by the State of Colorado Article XVIII and SB109

I believe that I have a debilitating medical condition that will be improved through the use of medical cannabis products. I have attempted to obtain the pertinent medical records as to confirm that my debilitating medical condition is approved by the state of Colorado as it meets the standards appropriate for medical cannabis treatment. The physicians opinion on qualification for medical cannabis use is informed by my medical history, current medical status, past drug or medication abuse, and a physical exam.

• I understand that my purpose of consulting with this physician is only to determine whether my medical condition is defined as chronic or debilitating by Article XVIII and SB 109 and “in the context of a bona fide physician-patient relationship, that [I] might benefit from the medical use of [cannabis] in connection with a debilitating medical condition.” (Article XVIII)
• I understand that this physician’s determination is NOT prescription for medical cannabis as it does not define the type, frequency, or form of use nor recommend or imply purchase of cannabis from any specific dispensary or caregiver.
• I understand that if I choose to use cannabis for my condition that it may cause side-effects such as drowsiness, dizziness, decreased reaction-time, and decreased coordination and therefore will avoid hazardous activities such as driving or operating heavy-machinery while medicated.
• I understand that the physical exam I am receiving is NOT a comprehensive medical examination and that I must consult my primary-care provider for any and all changes to my physical or mental condition.
• I understand that the physician performing this examination is available for follow-up consultation on my use of medical cannabis and recommends an annual re-evaluation of your medical condition from your primary-care physician.

MY RIGHTS

Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), you have certain privacy rights concerning your healthcare information. Under this law, your health care provider generally cannot give your information to your employer, or share your information for marketing or advertising purposes, without your written consent. It is important that you understand that your information can be used and shared in the following ways.

• To Inform multiple health care providers who may be involved in your treatment directly and indirectly.
• To inform your family, friends, relatives, or others that you identify, who are involved in your health care or heath care bills.
• Threats to health and safety that involves you harming yourself or others •To make required reports to the police
• To provide information about employees, to employers, regarding worker’s compensation
• To obtain payment from third party payers.

I acknowledge that by signing here I have entered into a bona-fide physician-patient relationship that is established for the purpose of fulfilling the physician's role and have received and read a copy of my HIPPA privacy rights and UNDERSTAND THIS PERMISSION MAY BE REMITTED AT ANY TIME.

I HEREBY CERTIFY THAT THE ABOVE INFORMATION HAS BEEN COMPLETED TO THE BEST OF MY KNOWLEDGE.

If you are of childbearing age, please be aware that the use of cannabis during pregnancy may not be safe for the unborn child. If you think you are pregnant or are attempting to become pregnant our physicians recommend you abstain from cannabis completely.

I HEREBY CERTIFY THAT THE ABOVE INFORMATION HAS BEEN COMPLETED TO THE BEST OF MY KNOWLEDGE.