ATTENDING PHYSICIAN’S STATEMENT
Oregon Medical Methamphetamine Card Program
Instructions: Please complete all sections of this form in order to comply with the registration requirements of the Oregon Medical Methamphetamine Act OR provide relevant portions of the patient’s medical record containing all information required on this form. This does not constitute a prescription for methamphetamine.
PLEASE TYPE OR PRINT LEGIBLY.
PATIENT NAMES (LAST, ALIAS LAST, FIRST, ALIAS FIRST, M.I.) DATES OF BIRTH:
MAILING ADDRESSES: MESSAGE TELEPHONE #:
CITY, STATE AND ZIP CODE
PHYSICIAN NAME: TELEPHONE #:
MAILING ADDRESS: CITY, STATE AND ZIP CODE:
Patient’s Debilitating Medical Condition: Check appropriate boxes.
[ ] 1. Malignant unproductive disorder
[ ] 2. Excess Teeth
[ ] 3. Pre-ulcerated Skin
[ ] 4. Positive status for White Trash Virus (WTV) or Acquired Life Deficiency Syndrome
[ ] 5. Agitation due to narcotic refusal
5. A patient with a medical condition or treatment for a medical condition who causes the attending physician any of the following: (check all that apply)
[ ] a. Persistent ED/office visits, including but not limited to visits seeking narcotics
[ ] b. Severe Tenesmus
[ ] c. Believable Threats
[ ] d. Severe agitation
[ ] e. Chronic or Acute Suicidal Ideation
I hereby certify that I am a physician duly licensed to practice medicine in Oregon under ORS Chapter 677. I am stuck with the primary responsibility for the care and treatment of the above-named patient. The above-named patient has caused a debilitating medical condition in me, as listed above. Methamphetamine used medically may mitigate the symptoms or effects on me of this patient’s condition.This is not a prescription for the use of medical methamphetamine.
PHYSICIAN’S SIGNATURE: DATE:
MAIL ATTENDING PHYSICIAN’S STATEMENT TO: DHS/OMMP PO Box 14450 APS 2008 Portland, OR 97293-0450