MD Attestation Form

Notice and Acknowledgement of Attestation by Patient or Caregiver Prior to the Dispensing of Medical Cannabis

Pursuant to Code of Maryland Regulations (COMAR) 10.62.30.05, prior to medical cannabis being dispensed, either in person or by delivery, a registered patient or caregiver shall attest that he or she understands that he or she is not immune from the imposition of any civil, criminal or other penalties for certain conduct related to medical cannabis:


By my signature below, I hereby affirm and attest that I understand that I am not immune from the imposition of any civil, criminal, or other penalties for the following:


Numbe r

Description

Please check box.

1.

Operating, navigating, or being in actual physical control of any motor vehicle, aircraft, or boat while under the influence of medical cannabis


2.

Smoking medical cannabis in any public place


3.

Smoking medical cannabis in a motor vehicle


4.

Undertaking any task under the influence of medical cannabis, when doing so would constitute negligence or professional malpractice


5.

Smoking medical cannabis on a private property that:


  1. Is rented from a landlord;


  2. Is subject to a policy that prohibits the smoking of medical cannabis or marijuana on the property,



6.

Smoking medical cannabis on a private property that is subject to a policy that prohibits the smoking of medical cannabis on the property of an attached dwelling adopted by:


  1. The board of directors of the council of unit owners of a condominium regime;


  2. The governing body of a home owner’s association,


(As used in (5) and (6) of this attestation, vaporization of medical cannabis is not smoking.)



By my signature below, I affirm and attest that I understand that:


Numbe r

Description

Please check box.

7.

I am required to keep all medical cannabis away from children other than the Qualifying patient,


8.

I am required to take steps to prevent children from obtaining or using medical cannabis,


9.

It is illegal to transfer medical cannabis to any person, other than the transfer by a Qualified caregiver to the caregiver’s designated qualifying patient(s),


10.

Obtaining medical cannabis does not exempt a qualifying patient or caregiver from prosecution and penalties imposed by Federal law, including possessing, transporting, or using medical cannabis on any federal property.


These properties include, but are not limited to federal buildings and courthouses, federal parks, federal highways, and federal military bases. It is my responsibility as a patient/caregiver to know the locations under federal jurisdiction.


11.

Scientific research has not established the safety of the use of medical cannabis by pregnant women,


12.

The use of medical cannabis to treat a medical condition is not approved by the U.S. Food and Drug Administration,


13.

When I am in possession of medical cannabis, I will have my caregiver identification card and/or patient identification number with me and will present it upon request.


I attest that I understand my rights and obligations as set forth and agree to observe these requirements prior to taking possession of medical cannabis.



I attest that I understand my rights and obligations as set forth and agree to observe these requirements prior to taking possession of medical cannabis.


Name of Patient/Caregiver (Print)


Patient/Caregiver Signature


Witness Name (Print)


Witness Signature


Date


Patient/Caregiver Identification Number