Medical Marijuana Treatment Agreement

This treatment agreement is a document signed by the patient who is being recommended medical marijuana (hereafter referred to as medicine or medication). The purpose of the treatment agreement is to help you and your healthcare provider work together toward safe and effective symptom management and to avoid potential adverse issues.

Goal of Treatment
The goal of therapy is to reduce your symptoms and help you complete everyday activities.

You should know this medication will not cure you. It has major risks and side effects. That is why it is important for you and your treatment team to carefully monitor your use of the medication to see if it is the right medication for you. 

You should understand that the medication works best when you also use self-care skills and follow your care plan.

The medication is a controlled substance. A controlled substance is a drug or other substance that the U.S. Drug Enforcement Administration (DEA) has identified as having potential for abuse.

Do not drive, operate heavy machinery, or perform any other dangerous activities while taking the medication.

Do not drink alcohol while taking the medication.

Do not sell, lend, or in any way give the medication to any other person.

Unless advised by a physician, it is important to avoid taking the medication when also taking:

  • Benzodiazepines (such as Xanax, Valium, and Ativan)
  • Muscle relaxants (such as Soma or Flexeril) 
  • Hypnotics (such as Ambien or Lunesta) 
  • Prescription opioids

Medical Marijuana Intake Form