Patient Consent and Waiver of Liability

I, the undersigned, agree not to make any legal claim or complaint or commence any proceeding against The Omni Doctor and Omni Services LLC (hereinafter referred to as "Physician"), in providing me with a physician certification and registering me into the Compassionate Use Registry as required by the Compassionate Medical Cannabis Act of 2014 enacted by the Florida Legislature.

I am hereby giving voluntary informed consent to treatment with low-THC cannabis or medical cannabis. The Physician has sufficiently explained the current state of knowledge in the medical community of the effectiveness of treatment of my condition with high and low-THC or medical cannabis, the medically acceptable alternatives, and the potential risks and side effects. I understand that there are other treatment options and I am not obligated to seek treatment from this Physician.

I release the Physician from any and all actions, causes of actions, claims, complaints, and demands for damages, loss of life, injury, economic or the release employment loss, positive results on drug screens, damage to reputation or character, termination or service/care by another healthcare professional, or whatsoever arising directly or indirectly as a result of my Physician Certification and Compassionate Use Registry order with the State of Florida, and my use of low-THC or Medical Cannabis.

I hereby affirm I am assuming all risks associated with the use of low-THC or medical cannabis, both foreseeable and unforeseeable, that may occur now or anytime in the future.

I acknowledge that the Physician will submit my treatment plan quarterly to the University of Florida College of Pharmacy for research on the safety and efficacy of low-THC cannabis on patients as required by the Compassionate Medical Cannabis Act of 2014. I consent to the use ofmy treatment plan and medical information to be used in private research and publication by Omni Services LLC, or any other private company performing research on safety and efficacy or Medical Cannabis. The physician will register as the ordering physician of high or low-THC cannabis for the named patient in the Compassionate Use Registry maintained by the Florida Department of Health and will update the registry to reflect the contents of the order. The physician shall deactivate the patient's registration when treatment is discontinued.

Federal Food Theand Drug Administration (FDA) approves all drugs prescribed by physicians. Cannabis is not an FDA approved medication. The use of cannabis in any form has not been evaluated by the FDA. The use of cannabis is not intended to diagnose, treat, or cure any disease. The certification of a qualifying condition by this physician does not constitute a prescription to use low-THC or medical cannabis. The decision to use be cannabisshouldnotbased solely on this physician certification. The patient is advised to consult with their primary care physician, private legal counsel, and perform their own independent research before using low-THC or medical cannabis.

The physicians of Omni Services, LLC cannot write a prescription for cannabis and have no control over the content of the medication.The effects or the adverse risks of whichever cannabis product you decide to consume vary from patient to patient.

benefits The physicians of Omni Services, LLC may not be able to provide you with thoroughly researched conclusions regarding all the potential and adverse risks of cannabis use for your particular qualifying medical condition. The scientific research on cannabis is incomplete and does not meet the high requirements for all other medicines approved by the FDA.

The physicians of Omni Services, LLC will enter a dose and route order for the use of cannabis. The law allows a maximum 70-day supply of medication.You are solely responsible for administering cannabis as your condition warrants, as determined on the basis of your own judgment and are solely responsible for all the consequences.

Cannabis is generally tolerated well by patients. Any side effects tend to be mild and temporary, usually lasting one week or less as patients adjust. Common side effects include irritated throat, dry mouth, elevated heart rate, mild time and space disorientation, mild euphoria, a general sense of well-being, and in some instances drowsiness and decreased motivation. Any side effects must be reported to the Physician at the quarterly follow visit,or as needed during the interim. There is a very rare, but potentially serious, side effect known as "First Dose Psychosis" that may occur up with initial exposure to cannabis.

The Physician shall deactivate the patient's certification when treatment is discontinued. I acknowledge that the Physician will immediately deactivate and revoke my Compassionate Use Registry order if I am arrested for, charged with, and/or convicted of any cannabis related activities. I acknowledge that the Physician will not testify on my behalf for a medical necessity defense related to any criminal cannabis charges or other criminal or civil matters. Revocation of the Physician Certification will represent an immediate termination of the patient-physician relationship. Furthermore, I release the Physician from all subpoenas, interrogatories, attestations, or testimonies related to any criminal cannabis charges or other criminal or civil matters.

This release of liability is to be binding on my heirs, executors, and assigns. I have read, understand, and agree with all the statements in this form.

I certify the information provided to the Physician is true and accurate to the best of my knowledge.

Any person who fraudulently submits false, misleading, or inaccurate information to the Physician for the purpose of being ordered high or Anyperson low-THCor medical cannabis by such Physician commits a misdemeanor under Florida law, may be subject to prosecution, and cannabis will be removed from the Compassionate Use Registry.

I additionally certify that I have been given actual Notice and understand that, not withstanding the Compassionate Medical Cannabis Act 2014:

(i) Cannabis is a prohibited Schedule I controlled substance under federal law, The act does not provide any immunity from or affirmative defense to arrest or prosecution under federal law;

(ii) Participation in the program is permitting only to the extent provided by the strict requirements of the act;

(iii) Any activity not sanctioned by the act may be a violation of state or federal law and could result in arrest, conduction, or incarceration;

(iv) Growing, distributing, or possessing cannabis in any capacity, except through a federally approved research program, may be a violation of state or federal law and could result in arrest, conviction, or incarceration;

(v) Use of medical cannabis, or possessing a cannabis patient registry card, may affect an individual's ability to receive or retaining federal or state licensure and other areas;

(vi) Restrictions for Use & Administration: Pursuant to Section 381.986, Florida Statutes, patients are prohibited from smoking low-THC or medical cannabis. Patients cannot use or administer the product on any form of public transportation, in any public place, in their place of employmentrestricted by his or her employer, in a state correctional institution, on the grounds of a preschool/primary school/secondary school, on a school bus or in a vehicle, aircraft or motorboat.

(vii) Participation in the compassionate medical cannabis act program does not authorize any person to violate federal law or state law;