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State of Illinois Illinois Department of Public Health Illinois Medical Cannabis Pilot Program Physician Written Certification Form
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Document Date: 2014-12-16 16:58:34

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File Size: 477,72 KB

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Alzheimer's disease / glaucoma / ataxia / neurofibromatosis / spinal cord disease / arachnoiditis / traumatic brain injury / Tarlov cysts / hydrocephalus / myoclonus / cancer / Parkinson's disease Tourette’s syndrome / multiple sclerosis / HIV / causalgia Sjogren's syndrome / disease / seizures / TBI / acquired immune deficiency syndrome / dystonia reflex sympathetic dystrophy / rheumatoid arthritis / Crohn's disease / lupus / chronic inflammatory demyelinating polyneuropathy / postconcussion syndrome / residual limb pain nail-patella syndrome muscular dystrophy / myasthenia gravis / hepatitis C / amyotrophic lateral sclerosis / interstitial cystitis / spinal cord injury / /

Organization

ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION Name / Authority of the State / U.S. Veteran’s Administration / Illinois Department of Public Health / Illinois Illinois Department of Public Health Illinois Medical Cannabis Pilot Program Physician Written Certification Form / Illinois Illinois Department of Public Health Illinois Medical Cannabis Pilot Program / Illinois Department of Public Health Division of Medical Cannabis / Illinois Illinois Department of Public Health Illinois Medical Cannabis Pilot Program Physician Written Certification Form INSTRUCTIONS Type / /

Position

PHYSICIAN / E-mail Address Illinois Physician / PHYSICIAN INFORMATION ON FILE WITH THE / /

ProvinceOrState

Illinois / /

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