Scribd
Upload
527 views1 page

Primary Caregiver Designation Form

The document designates a primary caregiver to provide medical marijuana to treat illnesses including cancer, AIDS, chronic pain, and others. It certifies that the individual suffers from a qualifying illness and has a physician's recommendation to use medical marijuana. It designates a primary caregiver who will be responsible for providing the medical marijuana according to California law. The designation is valid for one year.

Uploaded by

justin368
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
527 views1 page

Primary Caregiver Designation Form

The document designates a primary caregiver to provide medical marijuana to treat illnesses including cancer, AIDS, chronic pain, and others. It certifies that the individual suffers from a qualifying illness and has a physician's recommendation to use medical marijuana. It designates a primary caregiver who will be responsible for providing the medical marijuana according to California law. The designation is valid for one year.

Uploaded by

justin368
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Designation of Primary Caregiver

(California Health & Safety Code 11362.5)

I, _________________________________________________________,
Print name legibly
hereby certify that I suffer from cancer, anorexia, AIDS, chronic pain, spasticity,
glaucoma, arthritis, migraine, or other serious illness and I have obtained a
recommendation or approval from a licensed physician to use medical marijuana
(cannabis) in treating my illness. (A copy of my recommendation or approval is
attached hereto).

I hereby designate ____________________________________________


Print name legibly
as my “Primary Caregiver,” in accordance with Health & Safety Code 11362.5(d)
and 11362.5(e), which read as follows:

(d) Section 11357, relating to the possession of marijuana, and Section


11358, relating to the cultivation of marijuana, shall not apply to a patient, or to
a patients primary caregiver, who possesses or cultivates marijuana for the
personal medical purposes of the patient upon the written or oral recommenda-
tion or approval of a physician.

(e) For the purpose of this section, “primary caregiver” means the
individual designated by the person exempted under this act who has consis-
tently assumed responsibility for the housing, health, or safety of that person.

I agree that I will consistently rely on the above-named person as the


primary source of my medical marijuana as a matter of my personal health and
safety. This designation shall remain in effect for a period of one year.

Dated: ______________________

______________________________________
Signature

NOTICE TO LAW ENFORCEMENT: Pursuant to the Constitution of the State of California, Amendment III,
Sec. 3.5(c), state law enforcement officials have “no power … to refuse to enforce a statute on the basis that
federal law or federal regulations prohibit the enforcement of such statute.” It is therefore your legal duty and
responsibility to respect and obey this agreement per the above-cited legislation, and to leave the individuals
and gardens herein described unmolested and unreported to federal authorities. Failure to follow state law may
result in legal action being taken against you. Thank you for your understanding and compliance.

You might also like