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 will explain 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 review 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 and My Florida Green 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. Athina Kyritsis'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. Athina Kyritsis MD to the current standard of 30 days’ notice of termination. Termination may be immediate at which time ATHINA KYRITSIS 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.
Dr. Athina Kyritsis will not recommend Medical Marijuana for a patient who is pregnant. By signing this consent, you attest to the fact that YOU ARE NOT pregnant. You aggree to notify Dr. Kyritsis or My Florida Green should you become pregnant as your certification will be canceled.
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.