The $135 fee includes your consultation fee and approval recommendation.
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What is the main problem for which you seek evaluation and treatment today (i.e. nausea, anorexia, spasms, pain, etc.)?
Less than 1 month
Less than 1 year
More than 10 years
List all of your current prescription medications. List the names, dosage, frequency of use, and how long taken of each.
List products that you use or have used in the past for the condition for which cannabis is used (intended), i.e. ibuprofen, aspirin, glucosamine, milk thistle, etc.
Do you or have you used nicotine, alcohol, or caffeine? If so list the frequency of use, years of use, and a quit day if applicable.
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By agreeing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.
You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions.
I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
HIPAA COMPLIANCE PATIENT CONSENT
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. This notice contains a patient’s rights section describing your rights under the law. You ascertain by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, and if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By agreeing to this consent and booking an appointment, you understand that:
Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.
RELEASE OF LIABILITY
I thoroughly understand that I must be able to provide proof of identity, proof that I have an Oklahoma State residence, can prove my identity with a government issued ID, and am legally able to obtain a physician’s approval or recommendation as dictated by OMMA (OAC 310 : 681).
I understand that the physician does NOT make any final approval of applicants submitted to OMMA and that I, the patient, must personally submit my application online to OMMA within thirty (30) days of a physician’s authorization, along with all of the required appropriate supporting documentation, a picture, and the required license fee in order for the OMMA to evaluate issuing me a License as dictated by legislation (OAC 310 : 681).
I fully affirm that I have a SERIOUS medical condition that adversely affects my quality of life. I have found or am interested in finding substantial relief and improvement in my condition.
I thoroughly understand that this medication is not regulated by the United States Food and Drug Administration (FDA), although it is regulated by the OMMA. In requesting an approval or recommendation for a license to use this plant as medication, I assume full responsibility for any and all risks (medical, occupational, legal, etc…) of this action.
I have been thoroughly advised that combusted plant material contains chemicals known as tars that may be harmful to my health. Should respiratory problems or other ill effects be experienced in association with its use, it should be discontinued and reported to a physician.
I have been thoroughly advised that non-FDA regulated substances by affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any hard resulting to me and/or other individuals as a result of my elective use non-FDA regulated plant-based substances.
The OMMA, according to OAC 310 : 681, provides for possession and cultivation for personal medical purposes of patients with physician recommendations. It was made absolutely clear to me, the patient, that the physician, staff, and representatives of this practice do not provide medication, nor are they encouraging any illegal activities.
I thoroughly understand that if I have any questions regarding legality, that it is my responsibility as the patient to visit the OMMA website where the answers to such questions may be obtained.
I, the patient, hereby request a consultation by the physician for purposes of determining the appropriateness of medical treatment. I understand that no claims about medical efficacy will be made by the physician. The physician, staff, and representatives are addressing specific aspects of my medical care, and, are in no way establishing themselves as my primary care provider. Should an approval or recommendation be made, I understand that there is a renewal date of two (2) years on the license. I understand that at two (2) years time, it is my responsibility to see the physician to assess the possible continuance of my license beyond the term of initial approval.
Furthermore, I, the patient, my heirs, assigns, or anyone acting on my behalf, holds the physician and his/her principles, agents, employees, and clinic absolutely free of any harmless from any liability.
I do not consent