Updated 7/10/13. I have been advised that a corporation is NOT a person for the purposes of the Act. Maybe we should invite Mitt to come on board.
Patient/Caregiver Agreement to Engage in the Medical Use of Marijuana
I,______________________________________, swear and affirm that I am a patient under the Michigan Medical Marijuana Act, Initiated Law 1 of 2008.
__A recommendation for use of marijuana for medical purposes (copy attached) was obtained from Dr._____________________________, a physician authorized under Part 170 of the public health code, 1978 PA 368, MCL 333.17001 to 333.17084, or an osteopathic physician under Part 175 of the public health code, 1978 PA 368, MCL 333.17501 to 333.17556, license I.D. number____________________, and dated___________________________, stating that in the physician's professional opinion, and after having completed a full assessment of the patient's medical history and current medical condition made in the course of a bona fide physician-patient relationship, that I am likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate the debilitating medical condition or symptoms associated with the debilitating medical condition.
or:
__A registry card duly issued by the State of Michigan Licensing and Regulatory Affairs (LARA) , number______________________(copy attached), has been issued to me which attests to a physician's recommendation that in the physician's professional opinion, and after having completed a full assessment of my medical history and current medical condition made in the course of a bona fide physician-patient relationship, I am likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate the debilitating medical condition or symptoms associated with the debilitating medical condition.
I hereby designate_______________________________ as my caregiver under that law, and agree to conform with the Act in the medical use of marijuana.
I,______________________________________, swear and affirm that I am at least 21 years of age and have agreed to assist with the above named patient's medical use of marijuana. I have not been convicted of any felony within the past 10 years and have never been convicted of a felony involving illegal drugs or a felony that is an assaultive crime as defined in section 9a of chapter X of the code of criminal procedure, 1927 PA 175, MCL 770.9a.
Signed this date:____________________________
Patient sign here:_____________________________
Signed this date:___________________________
Caregiver sign here:________________________________
/s/_________________________________
Print Notary Name:_____________________________________
Notary public, State of Michigan, County of _____________________.
My commission expires: __________________.
Acting in the County of ___________________.
All parties to this agreement should keep copies of this, the required medical documentation, and identification of the principals for their files.
This will not prevent arrest and due process, but will, as long as a court abides by the law, help prevent conviction and require the charges to be dismissed in accordance with Sec. 8 as long as the evidence shows both parties to be in conformance.
All that remains is to prove an amount necessary to ensure an uninterrupted supply.
