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

v: 20190304

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* 1. Please enter your first name:

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* 2. Please enter your last name:

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* 3. Please enter your date of birth:

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* 4. Please enter your email address

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* 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 certification and recommendations for Medical Marijuana in New York State. The New York State Medical Marijuana Program has many restrictions on patients and providers, and our job is to help you navigate this system as easily and effectively as possible.

Alternatively, you could either find another provider to certify and recommend Medical Marijuana in NYS for you, or you could not use Medical Marijuana.

We are focused on providing you with certification and recommendations for Medical Marijuana in New York State. Therefore our treatment will be restricted to certifying and recommending medical marijuana for you. You already have health care providers who are caring for you, and by signing this patient contract you agree to use these other health care providers for all issues that are not  Medical Marijuana certification and recommendation. If you have a medical emergency you should call 911 or go to your nearest hospital Emergency Room.


The goals of this medical marijuana are:

· to improve your ability to work and function at home.
· to help your condition and associated conditions as much as possible without causing dangerous side effects.


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

· becoming psychologically dependent on marijuana
· known or unknown interactions with other drugs
· possible drowsiness or decreased thinking and reacting ability
· becoming withdrawn, lose interest in my usual activities, start to feel sad, have changes in my normal sleep pattern
· severe nausea and vomiting
· disturbance of heart rhythm
·numbness of the limbs
·allergies to marijuana

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.
· If my dose of marijuana keeps going up, I understand that I may be developing a tolerance to marijuana. I agree to tell my primary care provider of this and consider a 3 week break from marijuana every 3-4 months.
· If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of becoming psychologically dependent.

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* 6.
I agree to the following:

· I have accurately completed MedCannabisConsultants’ patient information form and have, to the best of my knowledge, described the conditions and associated conditions that I have that make me eligible to receive medical marijuana
· I do not have any exclusionary 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 medical marijuana. I will not share, sell, or trade my medical marijuana. I will not take anyone else’s medical marijuana.
· I will keep my medical marijuana in a safe place.
· I will not increase my medical marijuana until I speak with my provider.
· My medical marijuana may not be replaced if it is lost, stolen, or used up sooner than prescribed.
· I will keep all appointments with or set up by my provider .
· I agree to my provider checking a NYS controlled substance report for controlled substances including medical marijuana.
· If I am capable of becoming pregnant, I agree to use birth control while I am taking medical marijuana.

Certifications and recommendations

All certifications and recommendations for the New York State Medical Marijuana Program will be made in accordance with New York State laws, rules and regulations.

Prescriptions from Other Providers

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.

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* 7. I understand and agree that MedCannabisConsultants staff and providers will not fill out paperwork for out of state marijuana access, work related forms or insurance related paperwork.

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* 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

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* 9. Medical records and informing other providers

I agree to inform my other health care providers that I am in the New York State Medical Marijuana program. I agree to let my provider communicate with my other health care providers at their discretion.

My medical records are necessary for MedCannabisConsultants to complete my certification or registration. I agree to provide these records to MedCannabisConsultants.

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* 10. Discharge from MedCannabis Consutants and revocation of New York State Medical Marijuana Program certification

I understand and agree that MedCannabis Consultants and its practitioners reserve the right to stop my New York State Medical Marijuana Program certification and discharge me from MedCannabis Consultants at any time at their sole discretion without cause.  If I am discharged,  MedCannabis Consultants may direct me to a list of other doctors in New York who certify and recommend medical marijuana, if they judge this to be appropriate.

 Such situations may include, but are not restricted to:
  • If in the judgement of  MedCannabis Consultants practitioners, medical marijuana is not needed or is harming me more than it is helping me
  • Not keeping MedCannabis Consultants appointments per current MedCannabis Consultants requirements
  • If I am taking anticoagulant or antiplatelet medications that in our judgement might pose a risk to me if taken with medical marijuana products
  • Pregnancy or nursing

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* 11. Communication requirements

I understand and agree that as a condition to be a patient of MedCannabis Consultants, I must have and maintain at all times a cell phone where we can successfully call and text you.

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* 12. 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.

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* 13. 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.

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