I agree to provide the physician with any and all copies of my MEDICAL RECORDS, if they exist, that document my medical conditions, as requested by the doctor.
I agree to obtain medical FOLLOW-UP at my personal medical doctor's office or get a personal doctor if I have none now and to return for FOLLOW-UP, as recommended by the physician. I understand this is an obligation to MY part for the continuity of care.
I understand that I must be a California State resident to obtain an approval or recommendation for the use of cannabis (i.e., Medical Marijuana) under California’s Compassionate Use Act of 1996 (Health & Safety Code #11362.5).
I have found or am interested in determining whether cannabis (i.e., medical marijuana) provides substantial relief and improvement of my condition. I have been assured that medical records relating to my care will be kept private and confidential and that no information will be printed, which would disclose my identity unless required by law.
California's Compassionate Use Act of 1996, (Health and Safety Code # 11362.5) provides for the possession and cultivation of cannabis (medical marijuana) for the personal purposes of the patient with a physician's approval or recommendation. It should be made entirely clear that the doctor, staff, and representatives of WeedRecs or personalRN, Inc. are neither providing cannabis nor are they encouraging any illegal activity in my obtaining or using cannabis (medical marijuana).
I affirm that I have a severe or debilitating condition that adversely affects the quality of my life. Thus I am seeking medical cannabis to provide relief for my state of health. I understand that medical marijuana is used in the treatment of medical conditions that are severe and debilitating. These conditions include but are not limited to the following: cancer, AIDS, hepatitis, anorexia, autoimmune diseases, arthritis, cachexia, chronic or debilitating pains, glaucoma, migraines, muscle spasms, spinal injuries, seizures, nausea, or any other chronic or persistently debilitating condition.
I fully understand that medical marijuana use may have side effects that include and may not be limited to the following: dry mouth, laryngitis, pharyngitis, apathy, lethargy, heart rhythm disturbances, headache, nausea, tremors, weight gain, sadness, loss of energy, hallucinations, anxiety, paranoia, decreased verbal or cognitive skills, impotence, abnormal sperm count, infertility, gynecomastia, altered libido, diminished respiratory capacity, risk in fetal exposure, addictive behaviors, and altered skin/body temperatures. I agree to immediately discuss any of there or unlisted conditions with my doctor.
Marijuana use may lead to diminished reproductive function in men and women, including decreased libido or the inability to conceive. It is NOT recommended that marijuana is used in individuals (men or women) trying to conceive, during pregnancy, or while breastfeeding.
I understand that benefits and risks associated with the use of marijuana are not entirely understood and that the use of marijuana may involve risks that have not been identified.
I am aware that marijuana is regulated by the Drug Enforcement Administration (DEA) and that a Notice of Compliance has not been issued under the Food and Drug Regulations (FDA) concerning the safety and effectiveness of the medical use of marijuana as a drug. I understand that there may be impurities and potency variations depending on the strain and the method used for its consumption.
I understand that medical marijuana use at work, while driving, or operating machinery may be hazardous to my health or persons around me. I assume full responsibility for my actions at all times while using medical cannabis. I certify that I will use marijuana responsibly - meaning not in the presence of minors or individuals that may be adversely affected by it. Use is limited to private settings.
I certify that I am not currently on probation, parole, or in a drug rehabilitation program. If the terms of my possible future probation or parole are violated, the recommendation for cannabis use may be revoked without notice.
I understand that a medical recommendation for medical marijuana use is limited to the State of California. It is not transferable to any other states. Nor is it transferable to other persons. I will not be transporting marijuana to another state or another country. I understand that there may be legal ramifications including and not limited to fines or imprisonment for doing so.
I agree to halt my use of cannabis and to discuss with my physician, if any symptoms of depression, suicidal ideation, or any cognitive of motor impairment develop while I am using medical marijuana.
If I develop respiratory (breathing) problems of any kind, I will report and discuss with my doctor immediately. I also fully understand that the benefits of medical marijuana may be achieved via other means than smoking. These include but are not limited to tea, tincture, cream, vapor, ointment, capsules, edibles, and other methods. Smoking of marijuana carries the same health risks as smoking cigarettes.
I acknowledge receipt of the Proposition 64 warning, which states that marijuana smoke is a chemical known to the State of California to cause cancer. I have no questions about this.
I understand that if I am to receive a medical recommendation, it will be based on my medical conditions, which includes my mental health status. It is not a prescription. It is not to be provided to other persons. Neither the doctor nor staff is dispensing.
I understand that preparation and intake questions may be addressed by my caretaker or qualified dispensary personnel. Required good faith physical evaluations and follow-up visits to all doctors that are needed to treat me will be continued. If I do not have a primary physician, I will seek one immediately.
I fully understand that the medical evaluation that I receive on this date is NOT to be utilized in any part for an application for State Disability or Workmen's Compensation. If I receive a medical recommendation, it does not constitute or imply support in any manner an application for State Disability or a Worker's Compensation case.
I certify that I have carefully read all the DISCLOSURES above with full understanding and agreement.
I certify that all information verbally transmitted to the doctor is genuine and correct. I am seeking a recommendation for my own, personal, medical use. In the interest of continuity of comprehensive medical care, I agree to be contacted in the future for follow-up on medical records, my health status or for reminders regarding renewal my physician's recommendation.
RELEASE OF LIABILITY: I understand there is no representation on the medical efficacy of marijuana by the doctor or the doctor's office staff. The doctor is NOT a part of my primary care providers.
I attest that I am over the age of 18 years.
I attest that I am physically present in the State of California.
If I have legal issues with regards to marijuana usage, I will consult with my attorney and law enforcement personnel. If I have work-related questions or concerns, I will consult with the Human Resources Department at my workplace immediately.
I agree to arbitrate within the State of California in the event of any dispute.