Patient Acknowledgement

I understand that the information I have been asked to provide is for the evaluation of my medical condition and to determine if it is a qualifying medical condition approved under the New York Medical Cannabis Program, and if I have not accurately and completely disclosed the requested information, it may adversely impact the provider’s ability to diagnose my condition and/or determine whether I qualify for medical cannabis per New York state law.

I certify:
I certify that the information I am providing is accurate and complete and has been offered only for the purpose of determining if I have a qualifying medical condition. I certify that my condition is chronic and debilitating to my quality of life. I certify that I am not seeking marijuana for illegal purposes.

I understand:
The medical provider, staff, or representatives of MarijuanaRx, LLC are neither providing, recommending, dispensing nor encouraging me to obtain medical marijuana.

The medical provider, staff, and representatives of MarijuanaRx, LLC are addressing specific questions regarding my qualification for entry into the New York Medical Cannabis program, and unless otherwise stated, are in no way establishing themselves as my medical provider beyond the requested evaluation/consultation. All patients should follow up with their primary care provider or mental health provider as appropriate.

MarijuanaRx, LLC recommends that all patients follow the advice of their primary care provider and/or mental health provider as appropriate.

Should an approval be made for my medicinal use of cannabis, there is a renewal date specified by the state. It is my responsibility to see the medical provider to assess the possible continuance of cannabis use beyond the term of approval.

I acknowledge that I am a resident of New York, I am at least 18 years of age and have not misrepresented any information to MarijuanaRx, LLC or if I am under 18 I am the Legal Guardian of the Patient.

I acknowledge that I have voluntarily sought an evaluation from MarijuanaRx, LLC and am in no way being coerced to do so.

I acknowledge that evaluation does not ensure a medical cannabis card and if a denial is issued, I am not entitled to a refund.

I acknowledge the federal government has classified marijuana as a Schedule 1 controlled substance. Schedule 1 substances are defined, in part, as having 1. a high potential for abuse; 2. no currently accepted medical use in treatment in the United States; and 3. a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution, and possession of marijuana even in states, such as New York, which have modified their state laws to treat marijuana as a medicine.