Advance Practice Established Patient Consent Question Title * 1. What is your full name? Question Title * 2. What is your birthday: Question Title * 3. What is your phone number: Question Title * 4. I agree I am being evaluated to verify my preexisting qualifying diagnosis that will allow me to access medicinal cannabis. I will provide written documentation, medication list, etc. from my PCP or Specialist verifying my qualifying condition. I consent to allow Stacy Kracher APRNRX with Advance Practice to verify my qualifying condition, in part, by medical history review. I agree to pay $105.00 for a (one-year) or $155.00 for (two-year) certification. There is no additional charge for grow-site or caretaker certificate. The payment does not include the Department of Health fee. I agree I have not misrepresented my medical condition in order to obtain this recommendation and it is my intent to use cannibals 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, cultivation and/or distribution of marijuana. Yes No Question Title * 5. I understand the federal government has classified marijuana/cannabis and CBD 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 Hawaii, which have modified their state laws to treat cannabis as a medicine. Yes No Question Title * 6. I understand that Cannabis has not been approved by the Food and Drug Administration for marketing as a drug. The “manufacture” of cannabis for medical use is not subject to any standards, quality control, or other oversight. cannabis may contain unknown quantities of active ingredients (i.e., can vary in potency), impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of the cannabis plant. Yes No Question Title * 7. I understand the use of cannabis can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. While using marijuana, I should 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 cannabis, I can be arrested for “driving under the influence.” Yes No Question Title * 8. I understand the potential side effects from the use of cannabis include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low 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. Cannabis may exacerbate psychosis in persons predisposed to those mental health disorders. In addition, the use of cannabis may cause a patient to talk or eat in excess, alter perception of time and space, and impair judgment. Many medical authorities claim that use of cannabis, especially by persons younger than 25, can result in long-term problems with attention, memory, learning, a tendency to drug abuse, and psychosis. Advance Practice recommends cannabis use only for the relief of serious qualifying conditions and not for habitual use. Yes No Question Title * 9. I understand that using cannabis while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and cannabis. Cannabis should not be within reach in the car and should not be extinguished in the vehicle’s ash tray. Yes No Question Title * 10. I agree to stop using cannabis and seek emergent medical attention, should I experience side effects that include but are not limited to, depression, psychosis, suicidal thoughts, crying spells, respiratory problems, nausea, vomiting, abdominal pain, insomnia, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends. Yes No Question Title * 11. I understand smoking or vaporing cannabis may cause respiratory problems and harm, including bronchitis, emphysema, laryngitis and/or death. In the opinion of many researchers, cannabis smoke contains known carcinogens (chemicals that can cause cancer) and smoking cannabis may increase the risk of respiratory diseases and cancers in the lung, mouth and tongue. In addition, cannabis smoking or vaping contains harmful chemicals. If I begin to experience respiratory problems when using cannabis, I will stop using it and seek medical attention. Yes No Question Title * 12. I understand there is a risk of drug interactions with cannabis and many medications. If I am taking medications or undergoing treatment for any medical condition, including psychiatric medications, I understand that I should consult with my treating providers before using cannabis and that I should not discontinue any medication or treatment previously prescribed unless advised by primary or specialty provider. Yes No Question Title * 13. I understand individuals may develop a tolerance to, and/or dependence on, cannabis. 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 cannabis, I should consider reducing or stopping my cannabis use and consult with my primary care provider. Yes No Question Title * 14. I understand signs of withdrawal can include feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness. Yes No Question Title * 15. I understand symptoms of cannabis 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, contact my primary care provider. Yes No Question Title * 16. I have had the opportunity to discuss these matters with the APRN-RX with Advance Practice and ask questions regarding anything I may not understand. I understand the APRNRX does not make recommendations as to the use of medical cannabis or diagnosis qualifying conditions. I acknowledge that Advance Practice provides general information of the nature of medical cannabis and verifies my qualifying condition. Advance Practice informed me of the risks, complications and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that Advance Practice informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits. Yes No Question Title * 17. I understand and agree that when under the influence and/or in possession of cannabis, a copy of your 329 card should be on your person at all times. Yes No Question Title * 18. I understand in order to stay in compliance with the State of Hawaii Department of Health regulations, it is required that you return for a review of your medical condition at least every year, or two years, if agreed upon. Yes No Question Title * 19. I understand and agree that the Medical Marijuana Laws in Hawaii The state of Hawaii established the Hawaii Medical Marijuana Act in 2000. This law removes state penalties for the use, cultivation, and possession of medical marijuana, by patients who possess a 329 card from their physician or nurse practitioner. Qualifying patients must register with the Department of Health regarding laws related to position and cultivation @ www.medmjehawaii.gov/medmj.welcome Yes No Question Title * 20. I am giving consent for Advance Practice to verify my qualifying condition and submit to the State of Hawaii Department of Health that I qualify for a Medical Marijuana 329 Card. I also understand and agree that if I am giving any dishonest or untruthful information will be discharged. Yes No Question Title * 21. Electronic Patient Signature: Question Title * 22. Electronic Provider Signature: Done