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 physician. I agree to obtain medical FOLLOW-UP at my personal medical doctor's office or obtain 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 personal 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 absolutely clear that the physician, 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 serious or debilitating condition that adversely affects the quality of my life. Thus I am seeking medical cannabis to provide relief for my medical condition. I clearly understand that medical marijuana is used in the treatment of medical conditions that are serious and debilitating. They 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 other chronic or persistent 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. This may include 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 fully 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 if 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/or the method used for its consumption.
I clearly 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, not in following locations: public, near schools, in parking lots, or while driving.
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 hold my use of cannabis and to discuss with my physician any symptoms of depression, suicidal ideation, or any cognitive of motor impairment I may have while 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 other 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 have no questions about this.
I understand that if I am to receive a medical recommendation, it will be based on my medical conditions. 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 qualifies 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 doctor, 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 true and correct. I am seeking a recommendation for my own, personal, medical use. I agree to be contacted in the future for follow-up on medical records, my health status or for reminders regarding renewing my recommendation. This is in the interest of continuity of comprehensive medical care.
CONSENT: I authorize WeedRecs to provide GREENRUSH INC. with a digital copy of my medical recommendation upon issuance for the purposes of electronic record keeping, to be transferred via secure email and/or API webhook integration. I understand that GREENRUSH INC. will maintain the digital copy of my medical recommendation on a HIPAA-compliant web server, and that I will be able to gain access to these electronic records through logging into the greenrush.com web portal.
RELEASE OF LIABILITY: I understand there is no representative on the medical efficacy of marijuana by the doctor or office staff. The doctor is NOT a part of my primary care providers.
On this date, I have had all my questions answered and issues addressed in my native language with regards to proper use of medical marijuana. I agree to contact my doctor(s) immediately if I have medical questions, issues, or concerns. If I have legal questions 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 also agree to arbitrate within the state of California in the event of any dispute.
