Medical marijuana physician certification form 2025

1. Click ‘Get Form’ to open the medical marijuana physician certification form in the editor.
2. Begin by filling in the Physician Information section. Enter your name, Arizona License Number, and select your type (MD, DO, NMD/ND, MD(H)/DO(H)).
3. Complete the Office Address, Telephone Number, and Email Address fields to ensure proper communication.
4. In the Qualifying Patient Information section, input the patient's name and date of birth.
5. Check one or more boxes that indicate the qualifying patient’s debilitating medical condition from the provided list.
6. If applicable, indicate any underlying chronic or debilitating disease or medical condition related to checked conditions.
7. As the physician, initial each statement confirming your diagnosis, examination details, and discussions about risks and benefits of medical marijuana.
8. Finally, sign and date the Physician’s Attestation section to validate your certification.

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