By checking the “AGREE” box, I am consenting to the following:

I understand refunds are not available for issues with the registration process with the PA Department of Health, once the phone consultation is completed with Green Choice Medical.

I understand that medical marijuana use for treatment of these conditions has not been approved by the Federal Drug Association (“FDA”).

I understand that the side effects may occur while l am taking medical marijuana. Side effects can include, but are not limited to: Headache, dizziness, inattention, inability to concentrate, suicidal ideation, altered libido or impotence, addictive behaviors, aggressiveness, may decrease reproduction function in men as well as women, decreased verbal skills, increased food consumption and weight gain, hallucinations, decreased motivation, rapid heart rate, confusion, increased talkativeness, reduced testicular size, anxiety or panic, decreased coordination. I agree to notify my physician/medical provider if I experience any adverse symptoms (side effects) and stop taking the marijuana immediately.

Estimating the proper marijuana dosage is very important. Symptoms of marijuana overdose include, but are not limited to nausea, vomiting, disturbances to heart rhythms and numbness of the limbs. If I experience these symptoms I will go to the nearest emergency room.

I understand that some patients can become dependent on marijuana. This means they experience withdrawal symptoms when they stop using marijuana. Signs of withdrawal symptoms, while generally mild, can include feelings of depression, sadness or irritability, restlessness or mild agitation, insomnia, sleep disturbances, unusual tiredness, troubled concentration, loss of appetite.

I understand that using marijuana while under influence of alcohol is not recommended.

I agree to tell my physician if I have ever had been psychotic or attempted suicide.

I understand that the Green Choice Medical physician/medical provider does not suggest nor condone that I cease treatment of medications that stabilize my mental or physical condition. I am aware that there are treatment and medication alternatives to medicinal marijuana for my condition.

I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and may contain unknown quantities of active ingredients, impurities and/or contaminants. In requesting an approval or recommendation for the use of this plant as medication I assume full responsibility for any and all risks of this action.

I understand that the use of cannabis may affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my use of medicinal marijuana.

I understand that the physician/medical provider, staff and representatives of Green Choice Medical are neither providing nor dispensing cannabis, nor are they encouraging any illegal activity in my obtaining medicinal marijuana.

I understand that should I be given a recommendation for medical use of cannabis, I understand that I must be regularly followed- up by a doctor and appear for a re-evaluation at a date specified by the physician/medical provider, usually one year after use.

My heirs, assigns, or anyone acting on my behalf, hold the physician/medical provider and his/her principles, agents and employees, or Green Choice Medical PLLC, free of and harmless from any responsibility and liability resulting from the use of cannabis. In case any claim or dispute arises, I agree to arbitrate such claims/disputes and I agree that Pennsylvania law will govern such claims/disputes.

I request a consultation by a physician/medical provider for the sole purposes of determining the appropriateness of medical cannabis treatment. I, the undersigned, understand that there are no representations about the medical efficacy of cannabis.

I understand that the physician/medical provider, staff, and representatives at Green Choice Medical PLLC are addressing specific aspects of my medical care, and, unless otherwise stated are in no way establishing themselves as my primary care provider. The physician/medical provider is only rendering an opinion regarding the therapeutic indication of the use of medicinal marijuana.