Alabama Administrative Code › Title 540 - ALABAMA BOARD OF MEDICAL EXAMINERS › Chapter 540-X-25 - PHYSICIAN RECOMMENDATION OF THE USE OF MEDICAL CANNABIS › Appendix A - Alabama Medical Cannabis Informed Consent

Current through Register Vol. 42, No. 9, June 28, 2024
A certifying physician may not delegate the responsibility of
				obtaining written informed consent to another person. The certifying physician
				must explain the information in each section of this form to the patient, or
				the patient's parent or legal guardian, and, if applicable, the patient's
				registered caregiver. Prior to the certifying physician completing the
				certification or recommendation for medical cannabis, the certifying physician
				and the qualified patient, or the patient's parent or legal guardian, and, if
				applicable, registered caregiver must initial each section and sign indicating
				that the certifying physician has explained the information on this form. The
				original form shall be retained in the patient's medical record, and a copy
				shall be provided to the patient, parent, or legal guardian, and, if
				applicable, registered caregiver.
Patient's Printed Name
				_______________________________________
Classification of medical cannabis:
The federal and state government have classified cannabis as a
				Schedule I controlled substance. Schedule I substances are defined, in part, as
				having (1) a high potential for abuse; (2) no currently accepted medical use
				for treatment in the United States; and (3) a lack of accepted safety for use
				under medical supervision. Federal law prohibits the manufacture, distribution,
				and possession of cannabis even in states, such as Alabama, which have modified
				their state laws to treat cannabis as a medicine.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
The approval and oversight status of cannabis by the
				FDA:
Cannabis has not been approved by the Food and Drug
				Administration for marketing as a drug; therefore, the "manufacture" of
				cannabis for medical use is not subject to any federal standards, quality
				control, or other federal oversight. Cannabis may contain unknown quantities of
				active ingredients, which may vary in potency, impurities, contaminants, and
				substances in addition to THC, which is the primary psychoactive chemical
				component of cannabis.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
The current state of research on the efficacy of cannabis
				to treat the qualifying conditions:
There is insufficient evidence to support or refute the
				conclusion that cannabinoids are an effective treatment for any of the
				recognized qualifying medical conditions. While there is evidence that
				cannabinoids may provide relief for some of the symptoms associated with the
				qualifying medical conditions, the research is not conclusive. Research in this
				field remains ongoing, and the science is developing.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
The potential for addiction:
Some studies suggest that the use of cannabis by individuals
				may lead to a tolerance to, dependence on, or addiction to cannabis. I
				understand that if I require increasingly higher doses to achieve the same
				benefit or if I think that I may be developing a dependency on cannabis, I
				should contact my certifying physician.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
The potential effect that cannabis may have on a
				patient's coordination, motor skills, and cognition, including a warning
				against operating heavy machinery, operating a motor vehicle, or engaging in
				activities that require an individual to be alert or respond
				quickly:
The use of cannabis can affect coordination, motor skills, and
				cognition; i.e., the ability to think, judge, and reason. Driving under the
				influence of cannabis can significantly increase the risk of vehicular
				accident, which escalates if alcohol is also influencing the driver. While
				using medical cannabis I should not drive, operate heavy machinery, or engage
				in any activities that require me to be alert and/or respond quickly, and I
				should not participate in activities that may be dangerous to myself or others.
				I understand that if I drive while under the influence of cannabis, I can be
				arrested for "driving under the influence" (Ala. Code §
								32-5A-191).
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
The potential side effects of medical cannabis
				use:
Potential side effects from the use of cannabis include, but
				are not limited to, the following: dizziness, anxiety, confusion, sedation, low
				blood pressure, impairment of short term memory, euphoria, difficulty in
				completing complex tasks, suppression of the body's immune system, an effect on
				the production of sex hormones that may lead to adverse effects, inability to
				concentrate, impaired motor skills, paranoia, psychotic symptoms, general
				apathy, depression, and/or restlessness. Cannabis may exacerbate schizophrenia
				in persons predisposed to that disorder. In addition, the use of medical
				cannabis may cause me to talk or eat in excess, alter my perception of time and
				space, and impair my judgment. Many medical authorities claim that use of
				medical cannabis, especially by persons younger than 25, can result in longterm
				problems with attention, memory, learning, drug abuse, and
				schizophrenia.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
The risks, benefits, and drug interactions of
				cannabis:
Signs of withdrawal can include feelings of depression,
				sadness, irritability, insomnia, restlessness, agitation, loss of appetite,
				trouble concentrating, sleep disturbances, and unusual tiredness.
Symptoms of cannabis overdose include, but are not limited to,
				nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the
				hands, feet, arms or legs, anxiety attacks, and incapacitation. If I experience
				these symptoms, I agree to contact my certifying physician immediately or go to
				the nearest emergency room. Numerous drugs are known to interact with cannabis,
				and not all drug interactions are known. Some mixtures of medications can lead
				to serious and even fatal consequences.
I agree to follow the directions of my certifying physician
				regarding the use of prescription and non-prescription medication. I will
				advise all my other treating physician(s) of my use of medical cannabis.
Cannabis may increase the risk of bleeding, low blood pressure,
				elevated blood sugar, elevated liver enzymes, or impairment of other bodily
				systems when taken with herbs and supplements. I agree to contact my certifying
				physician immediately or go to the nearest emergency room if these symptoms
				occur.
I understand that medical cannabis may have serious risks and
				may cause low birthweight or other abnormalities in babies. I will advise my
				certifying physician if I become pregnant, try to get pregnant, or will be
				breastfeeding.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
Termination of employment and cost
				coverage
:
The use of medical cannabis could result in termination from
				employment without recourse, and costs may not be covered by insurance or
				government programs.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
Research & compliance:
The patient's de-identified health information contained in the
				patient's medical record, physician certification, and patient registry may be
				used for research purposes or used to monitor compliance with Act
				2021-450.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
Certifications and recommendations are not
				prescriptions:
Certification or recommendation by a registered certifying
				physician does not constitute a prescription for medical cannabis.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
Registry identification card:
When in the possession of medical cannabis, the patient or the
				patient's caregiver(s) must have his or her medical cannabis use registry
				identification card in his or her possession at all times.
Cert. Physician Initials _____ Patient/Guardian/Caregiver
				Initials _____
I have had the opportunity to discuss these matters with the
				physician and to ask questions regarding anything I may not understand or that
				I believe needed to be clarified. I acknowledge that my certifying physician
				has informed me of the nature of a recommended treatment, including but not
				limited to, any recommendation regarding medical cannabis.
My certifying physician also informed me of the risks,
				complications, and expected benefits of any recommended treatment, including
				its likelihood of success and failure. I acknowledge that my certifying
				physician has explained the information in this consent form about the medical
				use of cannabis.
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Author:
Alabama Board of Medical
				  Examiners
Statutory Authority:
Code of Ala.
				  1975
, 34-24-53 and 34-24-53.1; §§
										20-2A-1, et. seq.