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Revolutionizing medicine with cannabis innovation

We provide CONFIDENTIAL, free evaluations (pursuant to VA. CODE §54.1-3408.3) for patients, virtual, and walk-ins, on the same day basis, and telemedicine.

As of July 1, 2022, the Commonwealth of VA no longer requires a VA Board of Pharmacy card in addition to our Cannabis Products Certification. Our up-to-date Cannabis Products Certification is all that is required. With this Certificate you may visit and consult with the qualified staff of any of Virginia’s Board of Pharmacy-designated dispensaries, to obtain the cannabis products that best suit your needs.

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Name

Date of birth

Phone

Address

ID or DL number

ID or DL expiration date

upload image of front of ID or DL

Have you been or are you prescribed any medication for mental Health?

Mental Health History ( All Diagnosis, past and present) State if you have ever had symptoms of

other

Select which Medications you are on or have previously been on

Risperidone®=Risperidone Clozaril®=Clozapine Zyprexa®=Olanzapine Seroquel®=Quetiapine, Abilify®=Aripiprazole Thorazine®=Chorpromazine, Haldol®=Haloperidol, Geodon®=Ziprasidone, Invega®=Paliperidone, Loxitane®=Loxapine, Prolixin®=Fluphenazine, Trilafon®=Perphenazine, Latuda®=Lurasidone, Vraylar®=Cariprazine, Saphris®=Asenapine, Stelazine®=Trifluoperazine, Rexulti®=Brexpiprazole

Is your mental health provider aware of your use or intent to use Cannabis products?

Do you give Dr. Q consent to contact your mental health provider regarding the safe use of cannibis products?

Name or provider

Location

Phone number

Reason for which you are seeking CANNABIS PRODUCTS

Do you use Tobacco products?

Alcohol use?

Cannabis usage?

Please describe; any negative cannabis useage effects

positive cannabis usage effects

Negative Symptoms that I am currently experiencing: (Check all that apply)

Abdominal Pain/Cramping Anxiety Depression Difficulty Remaining/Falling Asleep General Pain Headaches Irritable or Hyperactive Bowels Muscle Pain/ Stiffness Nausea/Vomiting Nerve Pain Ocular Pressure Opiate Dependence Poor Appetite Seizures Tremors Hurting yourself

other

Disclaimer

I am over 18 years of age and I am a US citizen residing in the Commonwealth of Virginia.

I understand and agree that Dr. Quinones is not my physician other than for the evaluation and approval of this CCANNABIS PRODUCTS certification.

·I agree to strictly comply with the regulations, terms and conditions of the Commonwealth of Virginia’s medical CANNABIS PRODUCTS use program. No CANNABIS PRODUCTS obtained by me shall be used for any other purpose than as directed by my certifying physician and consulting pharmacist.

· I understand CANNABIS PRODUCTS are not to be resold, distributed, or used by any other person.

· I fully accept the responsibility in using CANNABIS PRODUCTS and I certify I fully understand the potential risks related to the use of CANNABIS PRODUCTS.

· If I am being followed by a mental health care provider, I agree to inform them of, and discuss my intent to use CANNABIS PRODUCTS.
· If I start using CANNABIS PRODUCTS, I agree to tell my private practitioner/physician if I experience any one or more of the following:

⁕ Start to feel sad or have crying spells
⁕ Have changes in my normal sleep patterns
⁕ Lose my appetite
⁕ Become more irritable than usual
⁕ Become unusually tired
⁕ Withdraw from my family and friends
⁕ Lose interest in your usual activities

· In the event that I experience a severe adverse reaction, I am advised to immediately contact my physician. In the event that my physician is not available, I agree to call 911 for help, lie down and relax until help arrives.

· I agree to tell my private practitioner/physician if I have ever had symptoms of schizophrenia, bipolar disorder, psychotic episodes or attempted suicide. I also agree to tell my medical professional if I have ever been prescribed or taken medicine for any of these problems.

· I understand that Dr. Quinones does not suggest nor condone that I cease treatment of medications that stabilize my mental or physical condition.

· I am not pregnant, intending to become pregnant, or breastfeeding. I certify that I have read this document and declare that the information contained herein is true, correct and complete.

· In the event that I experience a severe adverse reaction, I am advised to immediately contact my physician. In the event that my physician is not available, I agree to call 911 for help, lie down and relax until help arrives.

· I understand and agree to keep all cannabis products OUT OF REACH OF CHILDREN to avoid harmful accidental ingestions

There are potential risks and side effects associated with the use of cannabis (marijuana). Overall, it is important to carefully consider the potential risks and benefits of using cannabis and to use it responsibly.ubuntu servers

Some possible risks and precautions to consider include (See SAMHSA website):
· Short-term memory loss: Cannabis can impair short-term memory and concentration, which can make it difficult to remember new information or to perform tasks that require focus and attention. Marijuana can cause permanent IQ loss of as much as 8 points when people start using it at a young age.

· Mental health: Studies link marijuana use to depression, anxiety, suicide planning, and psychotic episodes. It is not known, however, if marijuana use is the cause of these conditions. Review article covering adverse effects of cannabis, especially in adolescent use available upon request.

· Impaired judgment: Dizziness and drowsiness are both common and can increase the risk of falling and accidents. It is important to avoid driving or operating heavy machinery while under the influence of cannabis.

· Blood pressure changes: Cannabis use can cause changes in blood pressure, which can be particularly dangerous for people with preexisting cardiovascular conditions. It is important to discuss the use of cannabis with a healthcare provider if you have any underlying health issues.

· Increased heart rate: Cannabis use can increase heart rate, which can be dangerous for people with preexisting cardiovascular conditions. It is important to discuss the use of cannabis with a healthcare provider if you have any underlying health issues.

· Driving: People who drive under the influence of marijuana can experience dangerous effects: slower reactions, lane weaving, decreased coordination, and difficulty reacting to signals and sounds on the road. DO NOT DRIVE UNDER THE INFLUENCE OF MARIJUANA.

· Coordination problems: Cannabis use can impair coordination and increase the risk of accidents. It is important to NOT operate heavy machinery or engage in activities that require coordination and balance.

· Risk of addiction: Cannabis can be addictive, especially for people with a personal or family history of substance abuse. It is important to use caution and to seek help if you are concerned about your cannabis use.

· I am not pregnant, intending to become pregnant, or breastfeeding.

· One cannabis cigarette is as damaging to your lungs as smoking 5 filtered cigarettes. Therefore, Non-smoked cannabis (oils, gummies, etc.) are less harmful than smoked products.

I certify that I have read the potential risk of using cannabis products:
Yes or No
I certify that I have read this document, understand the risks and declare that the information contained herein is true, correct and complete.

I agree that the following statements are true and accurate:

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