4 Rev. 06/2013
Physician Statement for
Medical Marijuana Registry Application
, , state that I personally examined
(Physician’s Name) (Applicant’s Name)
on and that the examination took place in the context of a bona fide physician-patient relationship;
(Date of examination)
and that has a debilitating medical condition qualifying under AS 17.37.070.
I have considered other approved medications and treatments that might provide relief, that are reasonably available to the
patient, and that can be tolerated by the patient, and have concluded that the patient might benefit from the medical use of
Physician’s Signature: Date:
Physician’s License Number: __________________________
The physician must either be licensed to practice medicine in the state of Alaska or must be an offic er in the regular medical
service of the armed forces of the United States or the United States Public Health Service while in the discharge of their
official duties, or while volunteering services without pay or other remuneration to a hospital, clinic, medical office, or other
medical facility in Alaska.