LAC 46:XLV.7729. Appendix―Form for Recommendation for Therapeutic Marijuana

—THIS IS NOT A PRESCRIPTION— PHYSICIAN RECOMMENDATION FORM Section A. Patient’s Physician Information (Required) 1. Legal First Name | 2. Middle Initial | 3a. Legal Last Name 3b. Suffix (Jr., Sr., III, etc.) 4a. Full Professional Address (street, city (in LA), zip code) 4b. e-mail address 4c.fax number 5. City | 6. State | 7. Zip Code | 8. Telephone Number 9a. LSBME Registration No. for Therapeutic Marijuana 9b. Schedule I No. (Board of Pharmacy) for Therapeutic Marijuana No. _________________________ No. _________________________ Section B. Patient Information (Required) 10. Legal First Name | 11. Middle Initial | 12a. Legal Last Name 12b. Suffix (Jr., Sr., III, etc.) 13. Date of Birth 14. Full Address of Patient [street, city (in LA), zip code] Section C. Patient’s Debilitating Medical Condition(s) (Required) This patient has been diagnosed with the following debilitating medical condition: (A minimum of one condition must be checked) Section D. Form, Amount, Dose, and Instructions for Use of Therapeutic Marijuana (Required) Section E. Certification, Signature and Date (Required) By signing below, I attest that the information entered on this recommendation is true and accurate. I further attest that the above-named individual is my patient, who suffers from a debilitating medical condition and that this recommendation is submitted by and in conformity with Louisiana Law, R.S. 40:1046, and administrative rules promulgated by the Louisiana State Board of Medical Examiners, LAC 46:XLV.Chapter 77. Signature of Physician: X______________________________________ Date:_______________________