Patient Agreement and Informed Consent: Please read and initial in the spaces provided to indicate that you understand and agree to each item. Do not sign this agreement if you have questions about or do not understand the information you have received about medical marijuana. I _____________________________________________understand that medicinal marijuana is Patient’s Name considered a medicine to be used in treating or relieving the suffering caused by unfavorable medical conditions. I agree to notify the staff Physician(s) if I begin to experience ill effects, and I will discontinue the use of medicinal cannabis (marijuana) until further notice. Medical Green Doctors, Inc., its associates, and staff Physicians are not providing, dispensing, or encouraging me to obtain medicinal cannabis (marijuana) Medical Green Doctors, Inc., its associates, and staff Physicians are not altering the patient’s medical care, and are in no way establishing themselves as the primary or secondary care Physicians. Medical Green Doctors, Inc., its associates, and staff Physicians do not advise or condone that I discontinue treatment or medication that I presently take. In the event of any conflict with Law Enforcement or the dispensaries, I give my consent to have my name, date of visit, and only the required information to be released as needed for verification of my legal recommendation according to the prop 215 guidelines. I also give my consent to be enrolled in www.THEGREENDOCTORS.COM online verification website. (This will allow for 24 hour verification) Upon physician’s approval, payment must be made at the time services are rendered (no payment required for unapproved patients and no refund for rendered services.) Services that are paid for with a credit card or debit card are not eligible for payment challenges after services are provided. In the event of disputing a credit card transaction, I am irrevocably consenting to allow MEDICAL GREEN DOCTORS to use and disclose my protected health information to any credit card entity, bank or financing company when they request such information. Medical Green Doctors, Inc has explained to the patient, the nature and purposes of medical cannabis (marijuana) treatment, including its benefits and possible side effects, and has asked the patient if he/she had any questions regarding his/her treatment with medical cannabis (marijuana), and has answered those questions to his/her satisfaction. Liability Waiver: In addition, the undersigned, his/her heirs, assigns, or anyone acting on his/her behalf, holds the physician and his principals, agents, and lease managers, to be free and harmless from any and all responsibility for any and all unforeseen harm resulting to him/her and/or any other individuals as a result of his/her use of cannabis (marijuana). I certify that I have read this document and declare under penalty of perjury that the information contained herein is correct, true, and complete.