I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition(s) and attest that I do not intend to use my medical recommendation for the purpose of illegally obtaining, growing or distributing medical marijuana. It is illegal to film or record in this office with video camera, cell phone or any other recording devices, be it still image, video or audio. This is a direct violation of HIPAA regulations and patient/ doctor confidentiality. I am aware that my recommendation can be revoked at any time and legal actions will be taken if I have perjured or misrepresented myself or my medical condition, my intentions or falsified any medical records to the physician. I also hereby authorize Medmar Releaf Clinic(MRC), or its representatives to discuss my medical condition(s) for verification purposes only. Additionally, I acknowledge the attending physician informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana. The risks, complications and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge the attending physician informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and their risks and benefits. The physician may request that I visit another physician or specialist to further substantiate my condition. I will be informed of all the above mentioned regardless of whether or not I qualify as a patient. AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS. I hereby authorize (MRC) to disclose and verify my records as a patient to law enforcement should I be arrested or detained. I understand that (MRC) will only verify my being a patient for the purpose of providing proof as justification for possession. This is valid during the period of time for which the recommendation has been issued. I hereby authorize (MRC) to disclose and verify my records as a patient to marijuana dispensaries/co-op for the purpose of obtaining medicine. This is valid during the period of time for which the recommendation has been issued. I give permission for my medical records and file to be reviewed by another physician working with (MRC) I understand this might happen if the original doctor that evaluated me needs a secondary opinion, is not available, off premise, has moved or terminated his/her practice. I have been advised that the use of medical marijuana may affect my coordination, motor skills and cognition in ways that could impair my ability to drive and agree not to operate heavy machinery or to drive motor vehicles. I understand that side effects may occur while I am taking medical marijuana. Side effects of medical marijuana can include but are not limited to: Euphoria, difficulty in completing tasks, low blood pressure, sedation, dysphoria, dizziness, anxiety, confusion, impairment of motor skills, paranoia and overeating.I understand that chronic use of marijuana can lead to laryngitis, bronchitis, and general apathy. I understand the attending physician, staff and or representatives of Medmar Releaf Clinic (MRC) are neither providing, dispensing nor encouraging me to obtain medical marijuana. I also acknowledge that the attending physician, staff and or representatives of MRC will not be providing or discussing information regarding dispensary, co-op, delivery service or any other way to obtain marijuana. I understand some users might develop a tolerance to marijuana. This means higher and higher doses are required to achieve the same benefit. It is recommended for patients to have an intermission with the drug for at least 3 weeks every 3-4 months. If I think I may be developing a tolerance to marijuana, I will notify the attending physician. I understand the benefits and risks associated with the use of marijuana are not fully understood and the use of marijuana may involve risks that have not been identified. I accept such risk. I agree that if I am a female patient that I will contact my attending physician if I become or am thinking about becoming pregnant. I acknowledge that the use of medical marijuana may create a pass through problems to a fetus during pregnancy and to a baby during breast feeding. I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana. I should not be driving a vehicle while using marijuana and that I can get a DUI for driving under the influence. I am not permitted to smoke within 1000 feet of a daycare or school. I certify that I have read this document and acknowledge that my manipulation, alteration or falsification of this form, the MRC letter of recommendation, will result in the immediate termination of any legal right to my use of medical marijuana. The physician,staff and representatives of MRC are addressing specific aspects of my medical care and, unless otherwise stated, are in no way establishing themselves as my primary care physicians/provider. Furthermore, the undersigned , my heirs,assigns, or anyone else acting on my behalf, hold the physician and his principals, agents and employees, free of and harmless from any responsibility for any harm resulting to me and/or other individuals as a result of my medical marijuana use. I certify that I have read this document and understand its declarations. Please add any additonal information you would like the doctor to know below. Seventy days after initial visit, I agree to have MedMar Releaf Clinic automatically bill my credit card $50 every 45 days until I email a request to cancel my account. The change will be effective the following billing cycle.