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.
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