The following is a list of the only allowable medical conditions that are eligible for treatment with medical marijuana in Pennsylvania at the present time (Check applicable medical condition(s):

To qualify for treatment with medical marijuana, you MUST have one of these conditions and it is deemed that there would be benefit to the utilization of medical marijuana for your care. I will notify your primary care physician and appropriate medical subspecialists as well as indicate in your medical record under medications that you are certified to receive medical marijuana. This is done to ensure transparency of your participation in this program for your safety and for compliance with government regulations for this program. The form of treatment and dosing will be relegated to the professional staff at the dispensary. I require that any serious adverse events felt to be related to medical marijuana be reported to me as well as discontinuance from the program due to change in health status (including death). You understand that the use of these products is for your medical therapy and their use, like traditional prescribed medication, is restricted to use for the condition(s) indicated above and will not be shared. Failure to comply with this agreement will result in your certification being revoked and reported to the appropriate state regulatory agency. Your signature below signifies understanding and acceptance of these requirements.