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Patient Questionnaire
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Qualify

Are you a Florida Resident?

Do You Have Any Drug Allergies?

Qualifying Conditions


Please select the condition(s) in which you seek Medical Marijuana for. If other please specify, field must not be blank.

Health History: Please list any symptoms that are current and that you have been treated for:


Please check if any of the following activities are substantially limited or impaired (i.e. pain/weakness/impaired strength or ability) by the medical condition for which you seek medical marijuana: *


You may select multiple options.

Have you used cannabis in the past to treat your medical condition? *


Do you have a history of substance abuse or addictions? *


Does cannabis provide relief for your symptoms? (If yes, please specify, i.e. Lessens pain, improves sleep, increases appetite, etc.): *

How does cannabis compare to your prescribed medicines in relieving your symptoms? *

Preferred method of marijuana use as a medicine: *

You may select multiple options.


You do understand that smoking is harmful to your lungs and is not medically advised? *


Have you had any negative/adverse reactions from cannabis use? *


Additional Information that you consider relevant to the physician’s evaluation:


How likely are you to recommend us to someone you know?


Are there medical records that document your medical condition(s)?


Questions/Comments/Concerns/Suggestions


Practice Consents


I authorize the release of any medical information including the diagnosis and the records of any treatment or examination rendered to me or my child/dependant during the period of such care to my primary care physician, or other referring physicians, and to consultants if needed and as necessary to process prescriptions.  I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits otherwise payable to me.

 

Regarding information about my care, I give my permission for the office of ATHINA KYRITSIS, MD, to leave a message on my answering machine and/or voice-mail and to message me via email or electronic message, if necessary.  I understand that I will have access to a patient portal where I can review information regarding my care online. If at any time I decide to revoke this form of communication, I agree to directly notify the doctor.

 

In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial policies of this office.  Payment is required for all services at the time they are rendered.  We accept payment in the form of cash or credit card.  Your signature below signifies your understanding and willingness to comply with this policy. 

 

Our Notice of Privacy Practices provides information about how we may use and disclosed protected health information about you.  The notice contains a Patient Rights section describing your rights under federal and state law.  You have the right to review our Notice before signing this consent.  The terms of our notice may change.  If we change our notice, you may obtain a revised copy by contacting our office. 

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations.  We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to use our use and disclosure of protected health information about you for treatment, payment and health care operations.  You have the right to revoke this consent, in writing, signed by you.  However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent.  The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

Protected health information may be disclosed or used for treatment, payment, or health care operations.

The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this notice.

The Practice reserves the right to change the Notice of Privacy Practices.

The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions.

The patient may revoke this consent in writing at any time and all future disclosures will then cease.

The Practice may condition receipt of treatment upon the execution of this consent.

 

I consent to Photographs that may need to be taken for documentation, referral and educational purposes.  I understand these will not be made public.

 

By signing this form, I acknowledge that I understand the contents of the NOTICE OF PRIVACY POLICIES, detailing how my information may be used. I permit a copy of this authorization to be used in place of the original.  I have been offered a copy of the NOTICE OF PRIVACY PRACTICES but declined to accept a copy. Should I decide to request a copy, I agree to contact ATHINA KYRITSIS, MD as the Safety Officer and he/she will forward me a copy of the NOTICE OF PRACTICE POLICIES. 


HIPAA Patient Consent Form


Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patients Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Patient understands that:

• Protected health information may be disclosed or used for treatment, payment, or health care operations.

• The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.

• The Practice reserves the right to change the Notice of Privacy Practices.

• The Patient has the right to restrict the uses of their information

• The Patient may revoke the Consent in writing at any time and all future disclosures will then cease.

• The Practice may condition treatment upon execution of this Consent. No insurance can be billed on the patient’s behalf without this signed HIPAA consent form, therefore same day of service payment in full for any services will be required.


Malpractice Insurance Notice


Dear Patient, “Under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. However, certain part-time physicians who meet state requirements are exempt from the financial responsibility law. YOUR DOCTOR MEETS THESE REQUIREMENTS AND HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This notice is provided pursuant to Florida Law.” The undersigned patient, spouse and/or legal guardian(s) or parent(s) acknowledges that he has received a copy, read and understands this Medical Malpractice Insurance notice. Furthermore, the undersigned acknowledges this notice was not signed under duress, and that all of the patient’s questions relating heretofore have been answered to the patient’s satisfaction.


Informed Consent for Treatment with Medical Cannabis


As a resident of the State of Florida, I hereby agree to treatment with medical marijuana, also referred to as medical cannabis, for my medical condition. ATHINA KYRITSIS, MD has sufficiently explained the current state of knowledge in the medical community of the effectiveness of treatment of my medical condition with medical cannabis, the medically acceptable alternatives, and the potential risks and side effects. He/she has explained that the risks of treating my medical condition with medical cannabis are reasonable considering the potential benefits for my health. He/she has also explained the alternative options for treating my condition, including the option not to treat at all.

I am aware of the potential short and long-term effects of medicinal cannabis use according to the National Institute on Drug Abuse (NIDA). These side effects include but are not limited to; altered senses, altered sense of time, changes in mood, impaired body movement, difficulty with thinking and problem-solving, and impaired memory. Physical effects may include breathing problems, increased heart rate, problems with child development during and after pregnancy. Mental effects may include temporary hallucinations, temporary paranoia, and worsening symptoms in patients with schizophrenia. Marijuana use has also been linked to other mental health problems, such as depression, anxiety, and suicidal thoughts among teens. NIDA. "Marijuana." National Institute on Drug Abuse. 28 February 2017. https://www.drugabuse.gov/publications/drugfacts/marijuana. Accessed 30 June 2017.

I understand that the most likely outcomes of using medical cannabis for my condition include alleviating my symptoms and potentially decreasing the amount of other medications I need to control my symptoms. I further understand and accept that new, unanticipated, different, or worse symptoms might result and worsening of my condition or death may be hastened by the proposed treatment with medical cannabis. ATHINA KYRITSIS, MD will reviewed my current medications and condition(s) and has informed me of the potential risks of drug interactions with cannabis. Should any changes in my condition(s), side effects, and/or medications occur, I agree to notify ATHINA KYRITSIS, MD as soon as possible. I agree that ATHINA KYRITSIS, MD is a Consultant for Medical Cannabis and is not intended nor is he/she to be construed as my Primary Care Physician. I am fully aware of the risks, benefits, and drug interactions of cannabis.

I attest that I concur with my physician in believing that all currently approved products and treatments are unlikely to prolong my life. I believe medical cannabis will help to alleviate my suffering, I do not believe that there are other satisfactory treatment options that are as safe for my condition without side effects and I seek it for my medical treatment. I am aware and understand that cannabis can impair my coordination, cognition, and motor skills. I cannot fully anticipate its effects or duration and hereby agree to NOT operate a motor vehicle, operate heavy machinery or equipment, participate in any hazardous activities, or perform any other hazardous tasks until I have learned its effect on me. I agree to not do any of the above while I am under the “psychotropic" effects of medical cannabis, meaning any degree of mental impairment as a direct result of or as an additive result of medical cannabis with pre-existing medications.

According to the FDA, “The agency has received reports of adverse events in patients using marijuana to treat medical conditions. The FDA is currently reviewing those reports and will continue to monitor adverse event reports for any safety signals attributable to marijuana and marijuana products, with a focus on serious adverse effects associated with the use of marijuana. Information from adverse event reports regarding marijuana use is extremely limited; the FDA primarily receives adverse event reports for approved products. General information on the potential adverse effects of using marijuana and its constituents can come from clinical trials using marijuana that have been published, as well as from spontaneously reported adverse events sent to the FDA. Additional information about the safety and effectiveness of marijuana and its constituents is needed. Clinical trials of marijuana conducted under an IND application could collect this important information as a part of the drug development process.” Food and Drug Administration (FDA). “FDA and Marijuana: Questions and Answers”. 12A of 23A. https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm. 28 February 2017.

I am aware that the FDA has not approved marijuana or marijuana-derived products to be safe or effective for the treatment of any disease or condition. However, the FDA continues to facilitate companies through the study of clinical trials and research concerning the overall safety, effectiveness, quality, and use of marijuana. The FDA reviews applications to market drug products to determine whether those drug products are safe and effective for their intended indications. The FDA reviews scientific investigations, including adequate and well-controlled clinical trials, as part of the FDA’s drug approval process. The FDA relies on applicants and scientific investigators to conduct research. The FDA’s role, as outlined in the Federal Food, Drug, and Cosmetic Act, is to review data submitted to the FDA in a marketing application to determine whether a proposed drug product meets the statutory standards for approval. Additional information concerning research on the medical use of marijuana is available from the National Institutes of Health, particularly the National Cancer Institute (NCI) and NIDA. Food and Drug Administration (FDA). “FDA and Marijuana: Questions and Answers”. 6A of 23A. https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm. 28 Feb. 2017.

I understand that the use of medical cannabis may not be permitted by my employer and any questions regarding employee regulations should be directed to the Human Resources Dept., my employer or an independent employment attorney. I understand and accept that my eligibility for hospice care may be withdrawn if I begin treatment with medical cannabis and that hospice care may be reinstated if the treatment ends and I meet hospice eligibility requirements. Dr. Mark A. Vacker's possible recommendation regarding medical cannabis is a medical recommendation only. It is understood that if he is required to give testimony or act as a legal witness on my behalf, additional fees will be required to be paid in advance. I agree to follow ATHINA KYRITSIS's recommendations and failure to do so might cause an irrevocable conflict that may result in a termination of the doctor-patient relationship. Should this unfortunate event occur, I do agree that I will not hold Dr. Mark A. Vacker to the current standard of 30 days’ notice of termination. Termination may be immediate at which time Dr. Mark A. Vacker will withdraw as the Recommending Physician and I am free to seek other medical advice and a Recommending Physician.

I do understand the following and recognize that if I have any legal questions I am to seek independent legal advice:

MEDICAL MARIJUANA/CANNABIS IS AVAILABLE IN FLORIDA; HOWEVER, IT REMAINS ILLEGAL UNDER FEDERAL LAW. THE FDA’S & FEDERAL GOVERNMENT’S CLASSIFICATION OF MARIJUANA IS A SCHEDULE I CONTROLLED SUBSTANCE. Under the Controlled Substances Act of 1970, Schedule I substances are defined as having a high potential for abuse and addiction. I understand and accept that my health plan or 3rd party administrator and physician are not obligated to pay for care or treatment consequent to the use of medical cannabis unless required to do so by law or contract.

I understand and accept full financial responsibility for my treatment with medical cannabis and I am liable for all expenses consequent to its use and that liability extends to my estate, unless a contract between myself and the manufacturer or the cannabis states otherwise. I agree to keep my medical cannabis in a secure, child-proof lock box under my direct supervision.

Finally, I am fully aware that the medical use of cannabis does NOT include the following:

• The possession, use or administration of medical cannabis by smoking.

• The transfer of medical cannabis to a person other than the qualified patient for whom it was ordered.

• The use of medical cannabis on any form of public transportation, in any public place, in a qualified patient’s place of employment, if restricted by his or her public employer, in a state correctional institution, on the grounds of a preschool, primary school, or secondary school or any school bus or vehicle.

By signing this required consent, I agree to the above statements and give permission to have my de-identified health information be used for research purposes in requested or required at any time.


Disability Notice


This physician evaluation is solely to determine your suitability as a candidate/patient who could potentially benefit from the adjunct use Medical Marijuana as an addition to an integrated medical regimen. This visit is NOT to determine your current disability status or suitability to evaluate of employment to any degree of impairment or injury.


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