Medical Marijuana Certification

Name *

LAST INITIAL in lieu of last name is OKAY.

First Name

Last Name

Gender Pronouns

She/Her/Hers

He/Him/His

They/Them/Theirs

Other/Self-Describe

I confirm that I am currently a Pennsylvania resident. *

Dr. Jones is currently certified to provide Medical Marijuana cards only in the state of Pennsylvania.

I confirm

Dr. Jones’ primary role will be that of an evaluator for the appropriateness of adding medical marijuana to your wellness plan. Dr. Jones will not provide prescriptions for medications. *

As such, it is preferred (but not required) that a wellness team be in place while I go through this process (e.g., a primary care physician, a therapist, a psychiatrist) for collaboration purposes.

I understand

Dr. Jones is certified to evaluate those diagnosed with the following qualifying conditions: Post-Traumatic Stress Disorder (PTSD), Severe Chronic or Intractable Pain, & Anxiety Disorders. I understand that documentation of my diagnoses is required (*from my medical provider) prior to my appointment. *

*Upon scheduling, you will be asked to complete a Release of Information for your medical provider (e.g., a primary care physician, a therapist, a psychiatrist) in order for Dr. Jones to retain the necessary documentation.

I understand

I understand that Medical Marijuana Evaluations through PsychPhilly can not be covered by my Insurance Company *

PsychPhilly is not currently in-network with any Insurance Providers.

I understand