Marijuana has not been approved by the FDA for marketing as a drug. Therefore the "manufacture" of marijuana for medical use is not subject to any standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients, impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana. *

YES

The use of marijuana can affect coordination, motor skills, and cognition, such as 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 marijuana, I can be arrested for "driving under the influence." *

YES

Potential SIDE EFFECTS from the use of marijuana include, but are not limited to, the following: Dizziness, anxiety, confusion, cough, bronchitis, lung problems, sedation, low blood pressure, impairment of short term memory, euphoria, nausea and vomiting (hyperemesis syndrome), 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. Marijuana may exacerbate schizophrenia. In addition, the use of marijuana may increase eating, alter my perception of time and space and impair my judgement. *

YES

I understand that using marijuana while under the influence of alcohol, opioids/opiates, sedatives, or illicit drugs is not recommended. Additional side effects may become present when using both alcohol, opioids/opiates, sedatives, and illicit drugs with marijuana. *

YES

I have had the opportunity to discuss these matters with the medical provider and to ask questions regarding anything I may not understand or that I believe needed to be clarified. *

YES

Individuals may develop a tolerance to, and/or dependence on, marijuana. I understand that if I require increasingly higher doses to achieve the same benefit I could be developing a dependency on marijuana and should seek medical assistance. *

YES

Signs of withdrawal can include: feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness. *

YES

Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to go to the nearest emergency room. *

YES

If 420 Cannabis Clinic subsequently learns that the information I have furnished is false or misleading, the qualification for marijuana may no longer be valid. I agree to promptly meet with 420 Cannabis Clinic and/or provide additional information in the event of any inaccuracies or misstatements in the information I have provided. *

YES

I agree to contact a medical provider or the emergency department if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact a medical provider or the emergency department if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends. *

YES

I acknowledge that the 420 Cannabis Clinic provider informed me of the nature of the treatment of my medical condition, including but not limited to, voluntary treatment using medical marijuana. The provider also informed me of the risks, complications, expected benefits of medical cannabis, including its likelihood of success and failure. I acknowledge the medical provider informed me of any alternative treatment options including the alternative of no treatment, and the risks and benefits. *

YES

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