Check off symptoms associated with your primary condition. Select level of symptom severity. Level 1 - not severe, Level 5 - very severe
I understand that this Release and Acknowledgment contains IMPORTANT information about medical cannabis that the assessing Health Professional requires that I acknowledge and understand before he/she may issue a prescription and/or authorization for the use of medical cannabis.
I further understand that the consulting Health Professional will not necessarily be assuming care for me. He/She will, however, assess and evaluate the appropriateness of my request to use medical cannabis to assist in treating the conditions and associated symptoms that I believe; from my own personal experience, medical cannabis to be helpful in treating.
I accordingly confirm that the assessing Health Professional will be my medical practitioner for the sole purpose of medical cannabis authorization and/or prescriptions.
I agree not to make any claim or commence any legal proceedings against the assessing Health Professional, his/her practice, my family physician or any other involved Health Professionals (such as specialists) in relation to:
I am well aware that Health Professionals generally agree that medical cannabis;
I am well aware there is considerable debate and a great lack of consensus among Health Professionals about:
I am further well aware that the above listed medical concerns are further compounded by the lack of consistency and uniformity in available medical cannabis products. With conventional drug products, I generally consume a medication of a precisely known molecular quantity. I recognize that raw plant Medical Cannabis does not work this way. I appreciate that I will get varying compositions of different cannabinoids and varying proportions of different cannabinoids from strain of plant to strain of plant and even, to a lesser degree, from plant to plant of the same strain.
I further appreciate that there is significant uncertainty regarding the consistency of the medical cannabis drug product I may medicate with which further complicates and compounds the practical issue of medicating with an inconsistent drug product like medical cannabis.
I am further aware that ingesting a high dose of medical cannabis can cause nausea and disorientation.
I am seeking medical cannabis treatment and I confirm I have consulted with a Health Professional regarding alternative and conventional treatment options for my condition.
Despite all these medical concerns, debates and practical issues I honestly believe that for the treatment of my condition(s) and symptom(s) the benefits of medicating with medical cannabis outweigh the risks.
I agree to receive a “medical document” (i.e. prescription) for medical marijuana only from one Health Professional. I agree to purchase my marijuana only from a Licensed Producer. I am aware that possession of marijuana from other sources is illegal.
I agree to safely store my marijuana so that no other person can access it either deliberately or accidentally. I will ensure that no child or young person will be exposed to my medical marijuana either directly or indirectly. I will contact Poison Control immediately if any child gains access to my supply of medical marijuana.
I am aware that taking marijuana with other substances, especially sedating substances, may cause harm and possibly even death. I will not use illegal drugs (e.g. cocaine, heroin) or controlled substances (e.g. narcotics, stimulants, anxiety pills) that were not prescribed for me.
I will inform the Health Professional of all controlled substances that are prescribed to me by my regular Health Professional(s). I will inform my primary care Health Professional that I am being prescribed medical marijuana. I agree to have a medical assessment performed by my regular Health Professional at least every 12 months.
I am aware that marijuana use is not advisable during pregnancy and breastfeeding. I agree to inform my Health Professional if I am pregnant. If I become pregnant while being treated with medical marijuana, I will immediately stop using it until I have consulted with a Health Professional.
This is my decision, and I also do not support any claims made by my family, friends or other interested parties against said clinic and Health Professionals.
I hereby release Cann Grow Consulting, the assessing Health Professional, his/her clinic, my family Health Professional, and any other involved Health Professionals from any and all actions, claims, causes of actions, complaints (even by family and friends) and demands for damages, loss, or injury whatsoever arising directly or indirectly as a consequence to my use of medical cannabis and my Application to posses medical cannabis.
This release from liability is to be binding on heirs, executors and assigns. I also consent to the disclosure, sharing and use of my personal information and medical data by the assessing Health Professional, Health Canada, Cann Grow Consulting and my Licensed Producer. The information may be used to contact, assess and register the patient and for analysis and research to better help our members.
I understand and acknowledge that while the assessing Health Professional may execute a declaration that I stand to potentially benefit from medical cannabis, the assessing Health Professional will not serve as my primary care Health Professional. As such I agree, to seek regular medical care from my primary care Health Professional and that the assessing Health Professional will only deal with assessing his/her support for my medical cannabis use. I also consent to the assessing Health Professional notifying any specialists that have seen of my decision to use medical cannabis, and I accept any consequences of such notification.
I agree to notify my primary care Health Professional myself about my intent to use cannabis medicinally as cannabis can interact with other medications. If licensed, I agree not to resell or give away any of my medication. I agree to check with local bylaws in my area. I also agree that any legal actions will take place in Ontario and be governed by the laws of Ontario, Canada.
I agree to the terms of cancellation and rescheduling.
If an appointment is missed, patient may call back the number on the same day or next day. If we do not hear from the patient for more than 24 hours after missed appointment they fall into the no refund category.
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