MEDICAL MARIJUANA THERAPY FORM

1.             I am a physician licensed in the State of Maine.

2.             __________________ has been diagnosed by me as suffering from
                one or more of the following conditions (check applicable boxes below):

[   ] Persistent nausea, vomiting, wasting syndrome or loss of appetite as a result of:

(i) Acquired immune deficiency syndrome or the treatment thereof; or

(ii) Chemotherapy or radiation therapy used to treat cancer;

[   ] Heightened intraocular pressure as a result of glaucoma;

[  ] Seizures associated with a chronic, debilitating disease, such as epilepsy; or

[   ] Persistent muscle spasms associated with a chronic, debilitating disease, such as multiple sclerosis;

[  ]  Other______________________________________              (Under New Law 2009)

3.  In the context of my bona fide physician-patient relationship with the person named in paragraph 2
above, I have:

(a) discussed with the person the possible health risks and therapeutic or palliative benefits of the
 medical use of marijuana to relieve pain or alleviate symptoms of the person's condition, based
on information known to me, including, but not limited to, clinical studies or anecdotal evidence
reported in medical literature or observations or information concerning the use of marijuana by|
other patients with the same or similar conditions;

(b) provided the person with my professional opinion concerning the possible balance of risks
and benefits of the medical use of marijuana to relieve pain or alleviate symptoms in the person's
particular case; and

(c) advised the person, on the basis of my knowledge of the person's medical history and
condition, that the person might benefit from the medical use of marijuana to relieve pain or|
alleviate symptoms of the person's condition;

(4) The person named in paragraph 2 above disclosed to me that person's medical use of marijuana.

(4) The person named in paragraph 2 above is under my continuing care.
 
__________________________________                         ___________________
    Signature of Physician                                                                            Date

_____________________________________________
Printed Name of Physician and License Number

_____________________               ___________________          _______________
             Street                                                    Town/City                                   State

 ________________________
Office Telephone Number