MEDICINAL CANNABIS ATTESTATION FORM For South Dakota Probationers Seems To Be Unconstitutional

You can download a word doc of this form at the above hyperlink. I typed this up, because I couldn’t find this form anywhere online.

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NOTE: DO NOT FILE THIS PAGE (CSO USE ONLY). 

                                         MEDICINAL CANNABIS ATTESTATION FORM 

(Fill in the information below. For the Judge to consider granting a probationer’s request for medicinal cannabis, the probationer must provide a copy of this written certification form from their medical practitioner listing the debilitating medical condition consistent with SDCL § 32-20G-1(8).

I, ______________________________________________, the probationer’s medical practitioner, certify pursuant to SDCL § 34-20G-1(8) that the probationer, Jason Karimi, has a debilitating medical condition defined as 

_____________________________________________________. 

I also certify pursuant to SDCL § 34-20G-96 that the probationer’s use of medical cannabis is: 

1. Consistent with the medical standard of care for the treatment of the individual’s debilitating medical condition and any symptoms associated with the debilitating medical condition; 

2. Reasonable in light of my observation and the individual’s physical examination, diagnostic test results, medical history, and reported symptoms, and

3. Reasonable in light of the risks and benefits of medical cannabis as compared to the benefits of other treatment options for the individual’s debilitating medical condition and symptoms associated with the debilitating medical condition. 

I also certify pursuant to SDCL 34-20G-1(2) that I have a bona fide practitioner-patient relationship with the above-named person as 

a. On _____________________________, I completed an assessment of the patient’s medical history and current medical condition, including an appropriate in-person physical examination. I reviewed the following records in making my assessment: 

____________________________________________________________________________

b. This patient has been under my care since ________________________ for the debilitating medical condition that qualifies the patient for the medical use of cannabis, or the patient was referred to me by ________________________________________________, the practitioner caring for the patient’s debilitating medical condition that qualifies the patient for the medical use of cannabis. 

c. The patient has a reasonable expectation I will continue to provide follow up care to the patient to monitor the medical use of cannabis in the following way(s): 

____________________________________________________________________________

d. The relationship is not for the sole purpose of providing a written certification for the medical use of cannabis unless the patient has been referred by a practitioner providing care for the debilitating medical condition that qualifies the patient to the medical use of cannabis. 

I declare under penalty of perjury under the law of South Dakota that the foregoing is true and correct. 

Signed on the ______ day of ______________ 20______, at _________________________. 

                                                                                                         City or other location, State

____________________________________          ___________________________________

                 Practitioner Printed Name                                          Practitioner Signature

____________________________________________

                           Practitioner Business Name 

                                                                                                                              UJS 655 / 844

                                                                                                                                     07/01/2024

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