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Exhibit G

Health & Safety Code 11362.5

Physician Statement

 

This certifies that _________________________, is a patient under my medical care and supervision for the treatment of ____________________.

I have have discussed the medical benefits and risks of cannabis use with the patient as a treatment for these medical conditions. I recommend cannabis use for my patient.

If my patient chooses to use cannabis therapeutically, I will continue to monitor his/her condition, providing advice on his/her progress.

I understand and agree that I may be contacted to verigy the information in this letter. My patient authorizes me to discuss their medical condition and the contents of this letter, for verification purposes only. I am a physician licensed to practice medicine in the state of California.

____________________________________________
Patient's signature

____________________________________________
Physician's signature

____________________________________________
Physician's CA License #

____________________
Date

____________________________________________
Physician's name (printed)

____________________________________________
Address

____________________________________________
City, State, Zip Code

Patient's Member Number _________

____________________________________________
Physician's area code and phone number