Paradise Clinic           

702 255-MARA


RENEWAL Patient History

Date________________                                                                          Expiration Date of current Card  ________________


Name ________________________________________________                


Age___ Date of Birth  __/__/___ Social Security # ___ __ ____     Driver's Lic #_______________________ (or Nevada ID #)


Address: ________________________________________________________________________________


City_________________ State __Zip ___  Marital Status:  Married__ Divorced__ Single__ Separated__


Home phone:________________________  Work phone: _________________________


Cell phone:__________________________


Email: __________________________________________


Job:_________________________ Employer: ___________________________________________


Are you on Disability__ Medicare__Medicaid__ Veteran__How did you hear about us? patient referral__ news__Doctor referral__ Other________________


I, herein, disclose that I am not directly or indirectly associated with any local, state or federal law enforcement agency.  Initials ________


1.  Please indicate if you have been diagnosed with any medical problems including diseases of the liver, kidneys, intestinal tract, nervous system, and etc. _______________________________________________________________________

_______________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________

Heart Disease?  Explain________________________________________________________________


2.  ALLERGIES: _________________________________________________________________________________________________



3.  Please describe all surgeries you have had since last visit.  Please list the dates, the reason, , the doctor or doctors who performed the surgery and the hospital where the surgery was performed.


____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



4.  Chief Complaint(s):


Describe all of your medical problems for which you seek evaluation and treatment today or the reason you use or would like to use medical marijuana. 




____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


5.  List all current prescription medicines  and how often you take them:


______________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________


6.  Name, address, and DATE last seen by physicians (chiropractor, acupuncturist, etc) who takes care of you for your present problems: 


___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7.  Legal History


Are you on probation or parole? θ Yes θ No If yes, is it drug-related?  θ Yes θ No


8.  Do you have a pending cannabis case?   θ Yes θ No  


Have you eve been accused or arrested for drug sales or distribution of drugs or marijuana?   θ Yes θ No 



                                                                                                                                        Paradise Clinic

                                                                            3225 S Rainbow Blvd #204, Las Vegas, Nv 89146         702 255-6272


    RENEWAL Patient History

Date________________                                                              Expiration Date of current Card __________


Name ________________________________________________                


Age___ Date of Birth  __/__/___ Social Security # ___ __ ____     Driver's Lic #_______________________ (or Nevada ID #)


Address: ________________________________________________________________________________


City_________________ State __Zip ___  Marital Status:  Married__ Divorced__ Single__ Separated__


Home phone:________________________  Work phone: _________________________


Cell phone:__________________________


Email: __________________________________________


Job:_________________________ Employer: ___________________________________________


Are you on Disability__ Medicare__Medicaid__ Veteran__How did you hear about us? patient referral__ news__Doctor referral__ Other________________


I, herein, disclose that I am not directly or indirectly associated with any local, state or federal law enforcement agency.  Initials ________


1.  Please indicate if you have been diagnosed with any medical problems including diseases of the liver, kidneys, intestinal tract, nervous system, and etc. _______________________________________________________________________

_______________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________

Heart Disease?  Explain________________________________________________________________


2.  ALLERGIES: _________________________________________________________________________________________________



3.  Please describe all surgeries you have had since last visit.  Please list the dates, the reason, , the doctor or doctors who performed the surgery and the hospital where the surgery was performed.


____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



4.  Chief Complaint(s):


Describe all of your medical problems for which you seek evaluation and treatment today or the reason you use or would like to use medical marijuana. 




____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


5.  List all current prescription medicines  and how often you take them:


______________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________


6.  Name, address, and DATE last seen by physicians (chiropractor, acupuncturist, etc) who takes care of you for your present problems: 


___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7.  Legal History


Are you on probation or parole? θ Yes θ No If yes, is it drug-related?  θ Yes θ No


8.  Do you have a pending cannabis case?   θ Yes θ No  


Have you eve been accused or arrested for drug sales or distribution of drugs or marijuana?   θ Yes θ No 


Are you being investigated at work for possible drug use? _________


Have you been stopped by Authorities for possession? _________________________________________________________


9. Who did you medical marijuana recommendation or referral in the past? ________________________________________



10.  Have you ever been prescribed Marinol (Dronabinol)?  When _________ Physician's Name, Address and Phone: _______________________________________________________________________________________________________________________________________________________________________________________________________________


11.  List how you take your medical marijuana medication:


Smoke______     Number joints per day __________   


Combo  Smoke and pipe ___   Number joints per day _____   Amount in pipe_______  Pipe smoking per day _______


Edibles ______  Amount consumed per day _________  How often? _______


Vaporizer _____   Amount consumed per day ________  How often?


other________


Do you take prescription medicine for your chronic problem ___  Need less?____  How has it changed, if at all?


________________________________________________________________________________________________


12.  Emergency Phone number of family member, close friend or neighbor:


Name______________________________________________________________


Address____________________________________________________________


Phone #_____________________________________________________________  



Patient Signature  ___________________________________Date     ___/__/____


Print_____________________________________________


YOUR PRIVACY IS IMPORTANT TO US.


Please indicate if you would like our calls to be discreet and private when leaving a message      Yes___   No Need___

                                                   

Because your entire process of obtaining permission to use medical marijuana is in our hands and the Nevada Department of Health, you may be assured the utmost in Confidentiality.  We care.

                                             

The Doctor promotes the safe and responsible use of medical marijuana.  Please do not drive, use heavy machinery or work while impaired or risk the health or safety of others. You may require an adjustment period as with any mind/body altering medication in order to perform certain tasks.  Proceed slowly and with caution if you are a first time user of medical cannabis.

You will build up a tolerance to medicinal marijuana with continued use.  In order to be a responsible user of "prescription" medical marijuana you should familiarize yourself with the Nevada Medical Marijuana Program and Federal laws regarding marijuana.


THE LAW:

Admission into the Nevada Medical Marijuana Program doesn't diminish your responsibility to follow public health and safety laws: You may never drive, sail or fly under the influence of medical marijuana; you may never possess a firearm in public under the influence of medical marijuana; and you may not even go on an amusement park ride if you're under the influence of medical marijuana. (NRS 484.379, 488.400, NRS 493.130, NRS 202.257, NRS 455B.080)


I have read the possible side effects of using marijuana as medicine as presented by the doctor.


Initial Here _______


Physician Review: _______________________                         Date:___________





RELEASE OF LIABILITYParadise Clinic702 255-MARA (6272)



I ___________________________________________________am applying for the right to use medical marijuana for the use specifically discussed with the Physician. I attest that I have been informed of the risks and discussed the risks of using medical marijuana with the Medical Practitioner.

I hereby release the Doctor, associates and Medical practice from professional or personal liability in connection with my using medical Marijuana or obtaining a Medical Marijuana Identification Card. I am aware that I must adhere to the statutes of Nevada and that Federal law prohibits the use marijuana which may result in severe penalties for use, cultivation, distribution or possession.

and that it is my responsibility to get a State ID card.  I understand that my records are HIPPA protected and my information will not be shared unless required by Law. I agree to allow telephone, fax or mail verification of my participation.

I agree to not duplicate, share or alter my Physician’s Statement. If lost, I must obtain a new letter from the Doctor to license my legal use of cannabis in the state of Nevada. I further agree to carry my Nevada State Marijuana Card.

I will continue treatment with my personal Physicians and take my prescription medications as directed & monitor dose changes. I have been informed I may need less Pain, Blood Pressure and Diabetes Medicines.

I have been informed of side effects of marijuana and not to use while pregnant or nursing. I will follow up with this office. I permit all forms of communication including automated phone messages. If requested, I may have a copy of this document.


Signature_____________________________________ Print ____________________________Date_____



POSSIBLE SIDE EFFECTS OF MEDICAL MARIJUANAParadise Clinic (702) 255-MARA (6272)

“MEDICAL MARIJUANA” (MEDICINAL CANNABIS, CANNABIS, TETRAHYDROCANNABINOLS)

CONTRAINDICATIONS:

Hypersensitivity to tetrahydrocannabinol or dronabinol products hypersensitivity to sesame oil

PRECAUTIONS:

Cardiac disorders such as arrhythmias, cardiac ischemia (usually manifest as either angina or a heart attack), concomitant use of sedatives or other psychoactive drugs, elderly patients may be more sensitive to psychoactive effects, history of substance abuse, history of psychiatric illness.

Do not drive, operate machinery, or engage in hazardous activities. Do not use during pregnancy or lactation. COMMON ADVERSE EFFECTS:

Abnormal thinking, impaired perception, impaired judgment, loss of motivation, diminished short-term memory, loss of concentration, depersonalization, euphoria, anxiety, panic attacks, paranoia, confusion, hallucinations, depression, dizziness/vertigo, drowsiness, diminished inhibitions; impaired coordination, increased risk of accidents, dry mouth, nausea, vomiting, high or low blood pressure, irregular heartbeat, increased heart rate, and “red” flushing of skin

DRUG INTERACTIONS:

Ritonavir

PREGNANCY: CATEGORY C

Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Most prescription medications are classified in Category C.

BREAST FEEDING:

Potential risk; change in therapy or care plan may be advisable

AGE RESTRICTION:

Patients age 18 and older may qualify for the use of medical marijuana, however, this office will recommend only to patients 21 and older (extraordinary exceptions may apply with written parental consent.)

The Doctor has provided and/or discussed the side effects of Medical Marijuana, and has offered a

more comprehensive copy of the side effects of the medicinal use of cannabis.

________________________________ PLEASE PRINT YOUR NAME

_________________________________________________ (BRING TO YOUR OFFICE VISIT) PATIENT SIGNATUREDATE



HIPPA


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES at the Paradise Clinic and Methods of Communication Between You (patient) and Paradise Clinic and staff.

In general, the HIPAA privacy rule gives individuals the right to request on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative mean as sending correspondence to the individuals office instead of the individuals home. The Privacy Rule generally requires health care providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an author requested by the individual in person. I hereby acknowledge that I have read the Notice of Privacy Practices ('Notice') was given to me upon arrival at the Paradise Clinic.

For matters such as appointment reminders and other Protected Health Information, I wish to be contacted in the following ways (CHECK ALL THAT APPLY):

HOME TELEPHONE __IT IS OK TO CALL MY HOME PHONE. CELL TELEPHONE __ IT IS OK TO CALL MY CELL PHONE. WORK TELEPHONE __IT IS OK TO CALL MY WORK PHONE MAIL (USPS) ___Okay to send mail to my home addressPrint Name ______________________________________ Date_________________

X______________________________________ Signature

Note: if patient is a minor, parents/legal guardian must read and sign above