Please read, ask any questions you have, and sign if you understand and agree to these terms.

Please read, ask any questions you have, and sign if you understand and agree to these terms.

Question Title

* 1. Please enter your first name:

Question Title

* 2. Please enter your last name:

Question Title

* 3. Please enter your date of birth:

Question Title

* 4. Please enter your email address

Question Title

* 5. This is your agreement to be treated by MedCannabisConsultants and its providers. This patient contract lays out the terms of our relationship: what we do and what you do. 

Why are you being treated by MedCannabisConsultants and its providers?

The purpose of our relationship is to provide you with a personailzed plan for your CBD treatment.

Alternatively, you could either find another provider to make recommendations about CBD or use CBD on your own.

We are focused on providing you a personalized plan for your CBD treatment. Therefore our treatment will be restricted to recommending CBD for you. You already have health care providers who are caring for you, and by signing this patient agreement you agree to use these other health care providers for all issues that are not your CBD recommendation. If you have a medical emergency you should call 911 or go to your nearest hospital Emergency Room.

Goals

The goal of this personalized CBD plan is:

· to improve your quality of life by providing hope, health and healing with
CBD.

Risks

I understand that there are risks to using CBD including but not limited to such things as:

· known or unknown interactions with other drugs
· possible drowsiness or decreased thinking and reacting ability
· allergies to CBD

I have been told and understand and acknowledge that:

· If I drink alcohol or use street drugs, I may not be able to think clearly and I could become sleepy and risk personal injury.

Question Title

* 6. I agree to the following:

· I have accurately completed MedCannabisConsultants’ patient information form and have, to the best of my knowledge, described my conditions and associated conditions. 
· I do not have any exclusion conditions or caution conditions and have indicated that on the patient information form
· I agree that I am a resident of New York State and that I have received care and treatment in New York
· I am responsible for my CBD. I will not share, sell, or trade myCBD. I will not take anyone else’s CBD.
· I will keep my CBD in a safe place.
· I will keep all appointments with or set up by my provider .
· If I am capable of becoming pregnant, I agree to use birth control while i am taking CBD.


Prescriptions from Other Providers

I understand that CBD alone may not be sufficient treatment for my problems. I agree to participate in education programs provided by MedCannabisConsultants.  If I am on other medications from other providers, I agree to continue these other medications and continue seeing these other providers for my other medical or psychiatric issues.

Question Title

* 7. Upgrade to NYS Medical Marijuana Program

I understand that if I and my MedCannabisConsultants provider both agree, I can upgrade to become certified in the New York State Medical Marijuana Program at a price reflecting my participation in the MedCannabisConsultants CBD program participation.

Question Title

* 8. Health status changes

I agree to notify my primary care provider if any of the following changes in my health status happen:
  • I become pregnant or start nursing
  • I begin anticoagulant ("blood thinner") treatment (examples: coumadin, Plavix, Plendal, Xarelto)
  • I become sad or depressed
  • I develop schizophrenia or a psychosis
  • I have a heart attack (myocardial infarction) or develop frequent angina chest pains
  • I develop a severe rash


Question Title

* 9. Medical records and informing other providers

I agree to inform my other health care providers that I am taking CBD. I agree to let my provider communicate with my other health care providers at their discretion.

If my medical records are necessary for MedCannabisConsultants to complete my personalized CBD plan, I agree to provide these records to MedCannabisConsultants.

I understand and agree that MedCannabisConsultants staff and providers will not fill out paperwork for work related forms or insurance related paperwork.

Question Title

* 10. Data agreement

I understand  that  providers at MedCannabisConsultants  are constantly learning how to treat patients better. I understand and agree that my data may be used with other data to analyse and improve the medical marijuana experience of patients.

Question Title

* 11. I have:
  • read and understood this agreement
  • discussed it with my provider if I wanted to
  • been given the opportunity to ask questions if i wanted to

I understand this agreement and agree to abide by it.

Question Title

* 12. Please type your full name below to indicate that you have read, understand, and agree to this patient care agreement.

T