*I am being evaluated for a physician’s recommendation for medical marijuana. The physician will make this recommendation based, in
part, on the medical information I have provided. I have not misrepresented my medical condition in order to obtain this recommendation
and it is my intent to use marijuana only as needed for the treatment of my medical condition, not for recreational or non-medical
purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use,
sale/purchase and/or distribution of marijuana.
I have been informed of and understand the following:
* I must be a California resident to obtain an approval or recommendation for the use of (medical marijuana) under California’s Compassionate
Use Act of 1996 (Health & Safety Code Section 11362.5).
* I understand the cultivation, distribution, possession, and use of marijuana is federally illegal. The federal government has classified
marijuana as a Schedule I controlled substance. Schedule I substances are defined, in part, as having (1) a high potential for abuse; (2) no
currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical supervision. Federal
law prohibits the manufacture, distribution and possession of marijuana even in states, such as California, which have modified their state laws
to treat marijuana as a medicine.
* I understand that marijuana has not been approved by the Food and Drug Administration for use as a treatment modality. I understand that
marijuana for medical use is not subject to any standards, quality control, or other oversight. I understand that marijuana may contain unknown
quantities of active ingredients, can vary in potency, and may contain impurities, contaminants, and unknown substances.
* I understand that the use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. While
using marijuana, I will not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly. I
understand that if I drive while under the influence of marijuana, I can be arrested for “driving under the influence.”
* I understand that potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion,
sedation, low or high blood pressure, impairment of short-term memory, euphoria, difficulty in completing complex tasks, suppression of the
body’s immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or
restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of marijuana may cause me
to talk or eat in excess, alter my perception of time and space and impair my judgment.
* I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when
using both alcohol and marijuana.
*I agree to contact PureCann if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts,
or experience crying spells. I will also contact PureCann if I experience respiratory problems, changes in my normal sleeping patterns, extreme
fatigue, increased irritability, or begin to withdraw from my family and/or friends.
*I understand that smoking marijuana may cause respiratory problems and harm, including chronic bronchitis, emphysema and laryngitis.
Marijuana smoke is known to contain known carcinogens (chemicals that can cause cancer) and other harmful chemicals. Smoking marijuana
may increase the risk of respiratory diseases and cancers in the lung, mouth and tongue. If I begin to experience respiratory problems when
using marijuana, I will stop using it and report my symptoms to a physician.
*I understand that the risks, benefits and drug interactions of marijuana are not fully understood. If I am taking medication or undergoing
treatment for any medical condition, I understand that I should consult with my treating physician(s) before using marijuana and that I should
not discontinue any medication or treatment previously prescribed unless advised to do so by the treating physician(s).
*I understand that individuals may develop a tolerance to, and/or dependence, and/or addiction to marijuana. I understand that if I require
increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I will contact the
*I understand that signs of withdrawal can include: Feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of
appetite, trouble concentrating, sleep disturbances and unusual tiredness.
*I understand that symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart
rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to go to the
nearest emergency room.
*If the physician or staff at PureCann subsequently learn that the information I have furnished is false or misleading, the recommendation for
marijuana may no longer be valid. I agree to promptly meet with the physician at PureCann and/or provide additional information in the event
of any inaccuracies or misstatements in the information I have provided.
*I have had the opportunity to discuss these matters with the physician and to ask questions regarding anything I may not understand or that I
believe needed to be clarified. I acknowledge that the physician at PureCann has informed me of the nature of a recommended treatment,
including but not limited to, any recommendation regarding medical marijuana. The physician also informed me of the risks,
complications and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge the
PureCann physician informed me of alternatives to the recommended treatment, including the alternative of no treatment, and the risks
*I affirm that I have a serious medical condition that adversely affects my quality of life.
*I am not currently in any drug or alcohol rehab program.
*I agree, the undersigned, my heirs, assigns or anyone acting on my behalf, hold the physician and PureCann, the principals, the agents
and employees free and harmless of any liability resulting from the use of medical cannabis.
*I am not a student in in high school.
*I am seeking a recommendation for my own, personal medical use.
*I have read the disclosures and conditions above with full understanding and agreement.
* I hereby authorize PureCann to disclose my records solely for the purpose of verification. I understand that I am only verifiable as a current
medical marijuana patient for the period of time for which the recommendation for medical marijuana has been issued by my PureCann
* I hereby authorize PureCann to verify my status as a PureCann patient via the PureCann online or phone-in Patient Verification System.
* I hereby authorize the use and disclosure of my PureCann patient records, except for personal identifying information, for use in data analysis
of cannabis-treated patients.
* I hereby authorize PureCann to disclose and verify my medical records to law enforcement should I be arrested or detained related to my
possession or use of medical marijuana. I understand that PureCann will only provide verification of my patient status for the purpose of
providing proof to justify my possession of medical marijuana. I understand that I am only verifiable as a current medical marijuana patient for
the period of time for which the recommendation for medical marijuana has been issued by my PureCann physician.
*In the event that I decide to apply for the voluntary state Medical Marijuana ID Card program, I understand that the physician at PureCann will
be contacted by the state and will be required to sign a document stating that I was approved for the use of medical cannabis in order for my
application to be complete. I hereby authorize PureCann and its physicians to release medical information to the California Department of
Public Health and/or as may be necessary for the issuance of the state ID card. I understand that this information may not be further disclosed
or used by the recipient for any other purpose without my authorization, except as permitted by state law governing access to the statewide
registry of authorized ID card holders. This authorization expires one year from the date set forth below. I understand that I have the right to
withdraw my authorization at any time except to the extent that action has been taken on reliance on this authorization. I understand
that if I revoke this authorization, I must do so in writing. I understand that authorizing the disclosure of this health information is
voluntary, I can refuse to sign, and PureCann will not condition my treatment on my providing authorization for the requested use or
disclosure. Notwithstanding anything to the contrary, this authorization will expire no later than twelve (12) months from the date of my
signature below. I understand that I am entitled to receive a copy of this authorization.