SHARING AND PRIVACY

I agree to share my Name, Phone Number, and Email Address with goodblend / Parallel / Surterra Holdings for marketing purposes.

I understand that no confidential medical information will be shared without my written consent.

PATIENT AGREEMENT AND CONSENT FORM TO USE MEDICAL MARIJUANA

I understand that under the Controlled Substance Act of 1970 cannabis is categorized as Schedule I, defining it as highly addictive and having the potential for abuse; it may contain unknown quantities of active ingredients and/or other impurities.

I understand that cannabis is a medicine used in treating the suffering caused by serious and debilitating medical conditions. I understand that cannabis smoke contains chemicals such as tars that may be harmful to my health and known carcinogens that may increase the risk of respiratory diseases and cancers of the lungs, mouth, and tongue. I acknowledge that I have been advised not to drive vehicles, operate machinery, or participate in any activity that requires safe judgment or analytical abilities while under the influence of cannabis.

I understand that there are potential risks combining alcohol/other substances and medications with cannabis. I assume any such risks and responsibilities and will discontinue cannabis use if I notice any unwanted symptoms or side effects. These effects can include but are not limited to: nausea, lethargy, upper respiratory problems, difficulty with short-term memory, anxiety, headaches, paranoia, loss of coordination, and psychological dependence on cannabis. I understand that withdrawal symptoms may occur upon discontinuing its use. These may include feelings of depression, sadness or irritability, restlessness or mild agitation, insomnia, sleep disturbance, unusual tiredness, trouble concentrating, and loss of appetite.

I understand that it is my responsibility to see my physician to assess the possible continuance of medical marijuana use beyond the expiration date. Any unauthorized release of information in this record is forbidden under federal HIPAA laws and I understand that I have only authorized this practice to confirm the following identifying information: name, date(s) seen, date of birth, date of expiration, and diagnose(s).

RELEASE OF LIABILITY

The physician, staff, and representatives of this practice are addressing specific aspects of my medical care and are in no way establishing themselves as my primary care provider. The physician is providing medical advice regarding the therapeutic value of the use of medical marijuana. Furthermore, the undersigned or anyone acting on my behalf, hold the physician and his/her agents and employees free of and harmless from any responsibility for any harm resulting to me and/or other individuals in a result of my cannabis use.