Medical Marijuana Consultation Physician Referral

Medical Marijuana Consultation

Medical marijuana consultation physician referral are certainly available to schedule online for any of our locations.

  1. To begin with, schedule your patient for an appointment.
  2. After that, transmit any relevant patient information through fax (888) 374-2546 or doximity messaging. In the event that you require a release form we have provided one below. You can print this screen and have your patient sign.

It is not a requirement to send patient information. But if you do so we appreciate it so we can prepare for your patient ahead of time. As soon as we see your patient you should expect our consultation note via secure fax or doximity secure messaging.

NEW PATIENTS TO CLINIC ONLY – GENERAL CONSENT FOR RELEASE OF MEDICAL RECORDS

Patient Name: ___________________________________________________________

Date of Birth:____________________________________________________________
I authorize (write your Doctor’s/Clinic’s Name (Not Ours)):

_____________________________________________________________________
Doctor’s/Clinic’s Address (Not our address):

_____________________________________________________________________
Doctor’s/Clinic’s Phone/Fax: ,

_____________________________________________________________________

to release my related medical records to:

SEAN DARCY, MD PROFESSIONAL CORPORATION
7307 W SUNSET BLVD, LOS ANGELES, CA 90046
Phone: (323) 790-4983, Fax: (888) 374-2546, Email: doc@e-zclinic.com

I understand that the physician or health care provider releasing my medical information and Protected
Health Information (PHI), pursuant to this request to SEAN DARCY, MD PROFESSIONAL CORPORATION, may not
be held liable for the misuse of such information when received by the person designated on this form. I understand that
the person designated on this form to receive my medical information may not further use or disclose my medical
information or PHI without my express authorization or unless another authorization is obtained from me or unless such
use or disclosure is specifically required or permitted by law. Unless otherwise revoked in writing, this authorization
expires in 10 years.

Patient Signature

 

______________________________

 

______________________________

Date