Physician Statement and Recommendation Pursuant to Nebraska’s Medicinal Cannabis Act (LB 474) and Nebraska Statutes Chapter 28 § 472
Patient Name: _______________________________
Date of Birth: _______________________________
Patient Identification: Nebraska
Recommendation Issued: ________________
Expiration Date: ________________ (Valid for 24 months from issue date)
This patient has been evaluated under my medical care, and upon reviewing their medical condition pursuant to Nebraska State Law, I have determined in my professional medical opinion that the potential benefits of cannabis use outweigh the risks for this patient’s condition.
The practice will continue to monitor patient condition and provide advice and support on their progress. This recommendation can be revoked at any time without notice and is void after the expiration date.
Warning: Patient is advised not to use cannabis if he/she is diagnosed with schizophrenia, has history of DUI, is pregnant or planning to be pregnant.
Patient Signature: _______________________________ Date: _______________________________
Physician Signature: _______________________________ Date: _______________________________
Physician Name: _______________________________ License Number: _______________________________ Clinic Name: _______________________________ Phone: _______________________________ Clinic Address: _______________________________
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