I certify that the information I am providing is accurate and complete and has been offered only for the purpose of determining if I have a qualifying medical condition. *

YES

I certify that my condition is chronic and debilitating to my quality of life. *

YES

I certify that I am not seeking marijuana for illegal purposes. *

YES

The medical provider, staff or representatives of 420 Cannabis Clinic LLC are neither providing, recommending, dispensing nor encouraging me to obtain medical marijuana. *

YES

The medical provider, staff and representatives of 420 Cannabis Clinic are addressing specific questions regarding my qualification for entry into the Virginia Medical Cannabis program, and unless otherwise stated, are in no way establishing themselves as my medical provider beyond the requested evaluation/consultation. All patients should follow up with their primary care provider or mental health provider as appropriate. *

YES

420 Cannabis Clinic recommends that all patients follow the advice of their primary care provider and/or mental health provider as appropriate. *

YES

Should an approval be made for my medicinal use of cannabis, there is a renewal date specified by the state. It is my responsibility to see the medical provider to assess the possible continuance of cannabis use beyond the term of approval. *

YES

I acknowledge that I am a resident of Virginia, I am at least 18 years of age and have not misrepresented any information to 420 Cannabis Clinic or if I am under 18, I am the Legal Guardian of the Patient. *

YES

I acknowledge that I have voluntarily sought an evaluation from 420 Cannabis Clinic and am in no way being coerced to do so. *

YES

I acknowledge that evaluation does not ensure a medical cannabis card and if a denial is issued, I am not entitled to a refund. *

YES

I acknowledge the federal government has classified marijuana as a Schedule 1 controlled substance. Schedule 1 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 Virginia which have modified their state laws to treat marijuana as a medicine. *

YES

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