By checking this box/submitting this form, I understand and agree that NuggMD will share my information with a third party physician or medical practice, and that NuggMD, third party physician or medical practice may in turn share my information, including his or her recommendation, if one is provided, with NuggMD.

I further understand and acknowledge that NuggMD may share my information with third party dispensaries, medical couriers, or other affiliates to facilitate the provision of NuggMD or medical services.

I am being evaluated for a physician's recommendation for medicinal use of marijuana. The physician will make this recommendation based, in part, on the medical information I have provided. I have not misrepresented my medical condition in order to obtain this recommendation and it is my intent to use marijuana only as needed for the treatment of my medical condition, not for recreational or non medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of marijuana. I have been informed of and understand the following:

1. The federal government has classified marijuana as a Schedule I controlled substance. Schedule I 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 California, which have modified their state laws to treat marijuana as a medicine.

2. Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore the "manufacture" of marijuana for medical use is not subject to any standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients (i.e., can vary in potency), impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.

3. The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. While using marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly. I understand that if I drive while under the influence of marijuana, I can be arrested for "driving under the influence."

4. Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory, euphoria, difficulty in completing complex tasks, suppression of the body's immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of marijuana may cause me to talk or eat in excess, alter my perception of time and space and impair my judgment. Many medical authorities claim that use of cannabis, especially by persons younger than 25, can result in long-term problems with attention, memory, learning, a tendency to drug abuse, and schizophrenia. Cannabis use is recommended only for the relief of serious symptoms, and not for habitual use.

5. 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. Cannabis should be treated as an open container of alcohol. It should not be within reach in the car, and should not be extinguished in the vehicles ash tray.

6. I agree to contact D’Ambrosio Medical Group, Inc. if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact D’Ambrosio Medical Group, Inc. if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends.

7. Smoking marijuana may cause respiratory problems and harm, including bronchitis, emphysema and laryngitis. In the opinion of many researchers, marijuana smoke contains known carcinogens (chemicals that can cause cancer) and smoking marijuana may increase the risk of respiratory diseases and cancers in the lung, mouth and tongue. In addition, marijuana smoke contains harmful chemicals known as tars. If I begin to experience respiratory problems when using marijuana, I will stop using it and report my symptoms to a physician.

8. The risks, benefits and drug interactions of marijuana are not fully understood. If I am taking medication or undergoing treatment for any medical condition, I understand that I should consult with my treating physician(s) before using marijuana and that I should not discontinue any medication or treatment previously prescribed unless advised to do so by the treating physician(s).

9. Individuals may develop a tolerance to, and/or dependence on, marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I should contact D’Ambrosio Medical Group, Inc.

10. Signs of withdrawal can include: Feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.

11. Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to contact D’Ambrosio Medical Group, Inc. immediately or go to the nearest emergency room.

12. If D’Ambrosio Medical Group, Inc. subsequently learns that the information I have furnished is false or misleading, the recommendation for marijuana may no longer be valid. I agree to promptly meet with D’Ambrosio Medical Group, Inc. and/or provide additional information in the event of any inaccuracies or misstatements in the information I have provided.

13. I have had the opportunity to discuss these matters with the physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge that D’Ambrosio Medical Group, Inc. has informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana.

14. D’Ambrosio Medical Group, Inc. also informed me of the risks, complications and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that D’Ambrosio Medical Group, Inc. informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits.

15. When under the influence and/or in possession of cannabis in public, a copy of your recommendation should be on your person at all times.

16. In order to stay in compliance with the California State Medical Board regulations, it is required that you return to your recommending physician for a review of your medical condition and an update of your recommendation every twelve months. An outdated recommendation may place the Doctor's Medical License in jeopardy with the Medical Board, and the patient is at risk of being ticketed and arrested

17. Patients giving any dishonest or untruthful information will be discharged.