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Physician Referral Forms Mississippi over 25
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Debilitating Conditions
* I am referring the referenced patient above for a consultation with The Healing Clinics, LLC based on the below selected, Mississippi qualifying condition(s). Mississippi Debilitating Conditions that Qualify for Medical Marijuana ***Check all that Apply***
Check all conditions that apply
Cancer
Parkinson's Disease
Huntington's Disease
Muscular Dystrophy
Glaucoma
Spastic Quadriplegia
Human Immunodeficiency Virus (HIV)
Acquired Immunodeficiency Syndrome (AIDS)
Hepatitis
Amyotrophic Lateral Sclerosis (ALS)
Crohn's Disease
Cachexia or Wasting Syndrome
Chronic Pain
Ulcerative Colitis
Sickle-Cell Anemia
Alzheimer's Disease
Agitation of Dementia
Post-Traumatic Stress Disorder (PTSD)
Autism
Pain Refractory to Appropriate Opioid Management
Diabetic/Peripheral Neuropathy
Spinal Cord Disease or Severe Injury
Severe or Intractable Nausea
Seizures
Characteristic of Multiple Sclerosis
Other (list below)
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