Med Card Now California

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MEDICAL INFORMATION
CALIFORNIA medical cannabis qualifying conditions shown below:
Check each medical problem that you suffer from or check other to have the doctor evaluate your unique condition. At least one box must be checked to qualify.
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DISCLAIMERS
RELEASE OF LIABILITY

I hereby state that I fully understand the potential risks and side effects related to the use of cannabis and in using cannabis therapeutically, I accept full responsibility in assuming the risks and side effects related to its use. I understand there is no representation on the medical efficacy of marijuana by the doctor or the doctor's office staff. I agree to allow communication regarding my personal health information (PHI) via email and/or SMS from the medical group, which includes the doctor, the medical staff, the principals, the agents and the employees. I understand that the doctor is NOT my primary care provider. I agree that the doctor and/or principals, agents, and employees, shall not be held responsible for any harm resulting to me and/or other individuals as a result of my medicinal use of cannabis. If I have legal issues with regards to marijuana usage, I will consult with my attorney and law enforcement personnel. If I have work-related questions or concerns, I will consult with the Human Resources Department at my workplace immediately. With my signature, I acknowledge that I have read the above requirements and that I understand and agree with all of the aforementioned statements listed.

DISQUALIFIERS

I UNDERSTAND THAT THE 100% MONEY BACK IF NOT APPROVED GUARANTEE ONLY COVERS MY APPLICATION IF I AM DISAPPROVED, I UNDERSTAND THAT IF I DO NOT COMPLETE THE PROCESS AND/OR ABORT THE APPLICATION I WILL NOT RECEIVE A REFUND. 

I UNDERSTAND THAT I MUST PHYSICALLY BE WITHIN THE STATE OF CALIFORNIA AT THE TIME OF STARTING & COMPLETING THIS APPLICATION.

I UNDERSTAND THAT IF I AM NOT IN THE STATE OF CALIFORNIA, I WILL BE DISQUALIFIED.

I UNDERSTAND THAT MEDICINAL CANNABIS IS A CONTROLLED SUBSTANCE UNDER STATE LAW AND PROHIBITED UNDER FEDERAL LAW.

I UNDERSTAND THAT THE MEDICAL GROUP DOES NOT RECOMMEND THE USE OF CANNABIS UNDER ANY TYPE OF PROBATION OR PAROLE.

I UNDERSTAND THAT IF I AM ON ANY TYPE OF PROBATION OR PAROLE, I CAN BE DISQUALIFIED.

I UNDERSTAND THAT THE CONSUMPTION OF ALCOHOL UNDER THE AGE OF 21 IS PROHIBITED BY THE NATIONAL MINIMUM DRINKING AGE ACT. I ACKNOWLEDGE THAT USING ALCOHOL AS A MINOR IS IN VIOLATION OF FEDERAL AND STATE LAW AND QUALIFIES AS HIGH-RISK BEHAVIOR.

I UNDERSTAND THAT IF I AM CONSUMING ALCOHOL AS A MINOR, I CAN BE DISQUALIFIED.

I UNDERSTAND THAT USE OF CANNABIS IS NOT RECOMMENDED DURING PREGNANCY, CONCEPTION OR BREASTFEEDING. I UNDERSTAND THAT IF I AM PREGNANT, BREASTFEEDING, OR TRYING TO CONCEIVE (WHETHER MALE OR FEMALE), I CAN BE DISQUALIFIED.

With my signature, I acknowledge that I have read the above requirements for disqualification and that I understand and agree with all of the aforementioned statements listed.

NOTICE TO CONSUMERS

The Compassionate Use Act of 1996 ensures that seriously ill Californians have the right to obtain and use cannabis for medical purposes where medical use is deemed appropriate and has been recommended by a physician who has determined that the person’s health would benefit from the use of medical cannabis. Recommendations must come from an attending physician as defined in Section 11362.7 of the Health and Safety Code. Cannabis is a Schedule I drug according to the federal Controlled Substances Act. Activity related to cannabis use is subject to federal prosecution, regardless of the protections provided by state law.

DIGITAL SIGNATURE
By electronically signing this document, you declare under penalty of perjury that the information on this form is true and correct.
Additionally, you are also aware that your recommendation may be revoked at any time if you have perjured or misrepresented yourself on this form.
Note: Filling out this questionnaire does not guarantee a recommendation.
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