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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: 2014-08-08 16:04:56

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MedicalCondition

Alzheimer's disease / glaucoma / neurofibromatosis / arachnoiditis / Tarlov cysts / pain / cachexia/wasting syndrome / hydrocephalus / cancer / multiple sclerosis / HIV / positive status ataxia / disease / causalgia Sjogren's syndrome / arthritis / Parkinson's disease Tourette’s syndrome myoclonus / acquired immune deficiency syndrome / dystonia reflex sympathetic dystrophy / severe fibromyalgia spinal cord disease / Crohn's disease / lupus / chronic inflammatory demyelinating polyneuropathy / fibrous dysplasia spinal cord injury / postconcussion syndrome / residual limb pain nail-patella syndrome muscular dystrophy / myasthenia gravis / hepatitis C / syringomyelia traumatic brain 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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