I understand that the evaluation, diagnosis and treatment by Dr. Johnson at IRIE Natural Health Center, may include, but is not limited to: ● Intake ● Physical examination ● Botanical medicine including cannabinoid medicine ● Bioidentical hormone replacement therapy ● Homeopathic remedies ● Nutritional Medicine (nutritional supplements, intravenous (IV) micronutrient therapy and intramuscular (IM) injection therapy) ● Dietary Counseling ● Telemedicine ● Acupuncture and Cupping ● Prescription medication to be filled at pharmacy ● Over- the counter medications As with all forms of medicine, I understand I am informed that there are risks and benefits with evaluation, diagnosis, and treatment, including but not limited to: Potential Risks: discomfort or minor bruising from Acupuncture or cupping: allergic reaction to prescribed herbs, supplements, or prescription medicine; a temporary aggravation of preexisting symptoms. Potential Benefits: restoration of the body’s optimal functioning capacity, relief of pain and/or disease symptoms, assistance in disease or injury recovery, and prevention of disease progression or recurrence. Notice to Pregnant Women: all female patients must alert Dr. Johnson if they know or suspect that they are pregnant, as certain therapies could pose a risk to pregnancy. Including medical marijuana and the potential dangers to fetuses caused by smoking or ingesting marijuana while pregnant or to infants while breastfeeding. By signing below, I acknowledge that I have been provided ample opportunity to read this form, or that it has been read to me. I understand that it is my responsibility to request that Dr. Johnson explain all therapies and procedure to my satisfaction during our consultations and I acknowledge that no guarantees have been offered to me concerning the results intended from the treatment Furthermore. I acknowledge and agree that in the event of a medical emergency or when urgent medical care is necessary, I will seek urgent care or go to the nearest emergency room. I intend for this consent form to cover the entire course of the treatment for my present condition, as well as any future conditions for which I may seek treatment at IRIE Natural Health Center. *** By signing this document I am agreeing that the information given is to the best of my knowledge. As part of the intake the doctor will base their recommendation on the information given. I certify that the information provided in this document is true to the best of my ability.

IRIE Natural Center for Health LLC

Medical Marijuana Certification Agreement

 Service Description: This agreement covers the provision of medical marijuana certification services, including consultation and issuance of a 2- year medical marijuana card.

Payment Terms:

Total Cost: [ ] $245 (Standard Fee) [ ] $170 (Discount for Food Stamp Recipients)

Payment Method: [ ] Credit Card [ ] PayPal  [ ]  Check [ ] Other: ___________

Payment Due Date:  Upon service delivery.

Cancellation and Refund Policy:

Full payment is required before issuing the medical marijuana card.

Fees are non-refundable once the card is issued.

Clerical Error Notification: Once the application is submitted to the  Arizona Health Department, it is the patient's responsibility to inform us of any clerical errors within 14 days of notification.  Failure to notify within this time frame may result in denied applications, and no refunds will be provided.

Dispute Resolution: In the event of a payment dispute, the patient agrees to contact our office for resolution before initiating a chargeback with the payment provider.

I acknowledge that I have read and understand the terms of the Medical Marijuana Certification Agreement. This includes the payment terms of $245 for the standard fee or $170 for the discounted fee for food stamp recipients, the cancellation and refund policy, clerical error notification, and dispute resolution. I agree to these conditions and understand that it is my responsibility to notify the office of any clerical errors within 14 days. Failure to do so may result in denied applications without refund.