MRA Consent Form

MRA MCHIGAN MARUJANA REGULATORY AGENCY
Marijuana Product Sales Receipt Number: Date Facility Received Marijuana Product:
The information in this section must be completed in order for this form
CONSENT FOR THE SALE OR TRANSFER OF MARIJUANA PRODUCT

Provisioning center employees must initial next to each testing category to acknowledge that testing has NOT been

performed on the marijuana product. Before the sale or transfer of the marijuana product by the provisioning center authorized to use this form, the licensee must fill out all required information.
By signing below, I consent to receive the above marijuana product that has not been tested as required by the Medical Marihuana Facilities Licensing Act, MCL 333.27101 et seq., and the Administrative Rules, R 420.301 et seq. I acknowledge that the use of untested marijuana products may lead to adverse reactions or worsen existing health conditions and such products are used at a patient's own risk. I understand that a patient or caregiver may take marijuana products to be tested at a state-licensed safety compliance facility and a list of those facilities can be

found by visiting www.michigan.gov/mra/ or by calling 517-284-8599.
Patient Signature *

Clear
Date *

Month Day Year
Date
Patient Printed Name *
Should be Empty:

MRA MCHIGAN MARUJANA REGULATORY AGENCY