La. Admin. Code tit. 46 § XLV-7729
-THIS IS NOT A PRESCRIPTION-
PHYSICIAN RECOMMENDATION FORM
Section A. Patients Physician Information (Required)
1. Legal First Name | 2. Middle Initial | 3a. Legal Last Name | 3b. Suffix (Jr., Sr., Ill, etc.) |
4a. Full Professional Address (street, city (in LA), zip code) 4b. e-mail address 4c.fax number | |||
5. City | 6. State | 7. Zip Code | 8. Telephone Number |
9a. LSBME Registration No. for Therapeutic Marijuana No. _______________ | 9b. Schedule I No. (Board of Pharmacy) for Therapeutic Marijuana No. _______________ | ||
Section B. Patient Information (Required)
10. Legal First Name | 11. Middle Initial | 12a. Legal Last Name | 12b. Suffix (Jr., Sr., Ill, etc.) |
13. Date of Birth | 4. Full Address of Patient [street, city (in LA), zip code] | ||
Section C. Patients Debilitating Medical Condition(s) (Required)
This patient has been diagnosed with the following debilitating medical condition: (A minimum of one condition must be checked) | |
___ Acquired Immune Deficiency Syndrome | ___ Intractable Pain |
___ Post-Traumatic Stress Disorder | |
___ Cachexia or Wasting Syndrome | ___ Any of the following conditions associated with autism spectrum disorder: |
___ Cancer | |
___ Crohns Disease | ___ (i) repetitive or self-stimulatory behavior of such severity that the health of the person with autism is jeopardized; |
___ Epilepsy | |
___ Multiple Sclerosis | |
___ Muscular Dystrophy | |
___ Positive Status for Human Immunodeficiency Virus | ___ (ii) avoidance of others or inability to communicate of such severity that the physical health of the person with autism is jeopardized; |
___ Spasticity | |
___ Seizure Disorders | |
___ Glaucoma | |
___ Parkinsons Disease | ___ (iii) self-injuring behavior; |
___ Severe Muscle Spasms | ___ (iv) physically aggressive or destructive behavior. |
Section D. Form, A mount, Dose, and Instructions for Use of Therapeutic Marijuana (Required)
_________________________________________________________________________________ |
_________________________________________________________________________________ |
Section E. Certification, Signature and Date (Required)
By signing below, I attest that the information entered on this recommendation is true and accurate. I further attest that the above-named individual is my patient, who suffers from a debilitating medical condition and that this recommendation is submitted by and in conformity with Louisiana Law, R.S. 40:1046, and administrative rules promulgated by the Louisiana State Board of Medical Examiners, LAC 46:XLV.Chapter 77.
Signature of Physician: X____________________________
Date: _____________________
La. Admin. Code tit. 46, § XLV-7729