Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:
a serious accident or fire
a physical or sexual assault or abuse
an earthquake or flood
seeing someone be killed or seriously injured
having a loved one die through homicide or suicide
*skips the Autism Spectrum Quotient assessment
If you cannot upload them here, email them to email@example.com or fax them to 833-629-0782. When you text me your receipt number, let me know where I can find your documents. Thank you. :)
I certify the information provided to the physician is true and accurate to the best of my knowledge.
Any person who fraudulently submits false, misleading, or inaccurate information to the Physician for the purpose of being recommended medical cannabis by such Physician commits a misdemeanor under Pennsylvania law, may be subject to prosecution, and will be removed from the Department of Health Medical Marijuana Program Patient Registry.
I additionally certify that I have been given actual notice and understand that, notwithstanding the Medical Cannabis Act of 2016 enacted by the Pennsylvania Legislature
I authorize the physician to obtain/have access to my medication history.
I authorize the physician's office to contact me by mobile phone.