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I, the patient, understand that medical marijuana is a medicine used in treating the suffering caused by serious and debilitating medical conditions. Serious and debilitating medical conditions include: Cancer, HIV/AIDS, PTSD, Epilepsy, Glaucoma, Cachexia, Cerebral Palsy, Muscular Dystrophy, Tourette Syndrome, Cystic Fibrosis, Osteogenesis Imperfecta, Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Neuropathic Facial Pain, Parkinson’s disease, ALS (Lou Gehrig’s disease), Crohn's disease, Sickle Cell disease, Complex Regional Pain Syndrome (Type 1 & Type II), Post Laminectomy Syndrome with Chronic Radiculopathy, MALS Syndrome, Ehlers-Danlos Syndrome, Wasting Syndrome, Uncontrolled Intractable Seizure Disorder, Interstitial Cystitis, Hydrocephalus with Intractable Headache, Intractable Headache Syndromes, Spasticity or Neuropathic Pain Associated with Fibromyalgia, Severe Psoriasis and Psoriatic Arthritis, Severe Rheumatoid Arthritis, damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity (any spinal cord injury), Terminal Illness Requiring End-Of-Life Care, Post Herpetic Neuralgia, Inflammatory Bowel Disease, Ulcerative Colitis, Vulvodynia and Vulvar Burning, Chronic Pain of at least 6 months duration associated with a specified underlying chronic condition refractory to other treatment intervention, any type of neuropathy; any condition that is severe, for which other medical treatments have been ineffective, and if the symptoms “reasonably can be expected to be relieved” by the use of medical cannabis.

Additionally, medical marijuana is used in the treatment of other chronic or persistent medical symptoms that:

1) Substantially limits the ability of the person to conduct one or more major life activities as defined in the Americans with Disabilities Act of 1990 (Public Law 101-336)

2) If not alleviated, may cause harm to the patient’s safety or physical or mental health

3) A chronic or debilitating disease or medical condition that causes severe loss of appetite, wasting, severe or chronic pain, severe nausea, seizures or severe or persistent muscle spasms, or glaucoma or post-traumatic stress disorder (PTSD)

I understand that side effects may occur while I am taking medical marijuana. Side effects of medical marijuana may include but are not limited to: euphoria, difficulty in completing complex tasks, low blood pressure, sedation, dysphoria, alterations in the perception of time and space, dizziness, anxiety, confusion, impairment to short term memory, inability to concentrate, suppression of the body’s immune system, increased talkativeness, impairment of motor skills, delayed reaction time, loss of physical coordination, paranoia, and increased eating.

Although smoking marijuana has not been linked to lung cancer, smoking marijuana can cause respiratory harm, such as bronchitis. Many researchers agree that marijuana smoke contains known carcinogens (chemicals that can cause cancer) and that smoking marijuana may increase the risk of respiratory diseases and cancers in the lungs, mouth and tongue. I have been advised that medical marijuana smoke contain chemicals known as tars that may be harmful to my health. I understand that there are many methods of intake that substantially reduce the harmful effects of smoking such as vaporizers, edibles, tinctures.

The physician, staff and representatives of Richard Koffler, MD are addressing specific aspects of my medical care and, unless otherwise stated, are in no way establishing themselves as my primary care physician/provider. Furthermore, the undersigned, my heirs, assigns, or anyone else acting on behalf, hold the physician and his/her principals, agents and employees, free of and harmless from any responsibility for any harm resulting to me and/or other individuals as a result of my medical marijuana use.

I understand that I must be a Florida resident to obtain an approval or recommendation for the use of medical cannabis.

I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and therefore may contain unknown quantities of active ingredients, impurities and/or contaminants. I understand the potential risks associated with an elevated daily consumption of medical marijuana including risks with respect to the effect on my cardiovascular and pulmonary systems and psychomotor performance, risks associated with the long-term use of marijuana, as well as potential drug dependency. I am aware that the benefits and risks associated with the use of marijuana are not fully understood and that the use of marijuana may involve risks that have not been identified. In requesting an approval or recommendation for the use of medical marijuana, I assume full responsibility for any and all risks involved in this action.

I have been advised that medical marijuana smoke contains chemicals known as tars that may be harmful to my health. Should respiratory problems or other ill effects be experienced in association with its use, it should be discontinued and reported to the physician immediately.

I was also advised that the use of medical marijuana 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 cannabis.

Florida’s Medical Marijuana Legalization Initiative — Amendment 2, approved November 08, 2016 — provides for the possession of medical marijuana for the personal medical purposes of the patient with a physician approval or recommendation. It should be made clear that the physician, staff and representatives of this practice are not providing medical marijuana, nor are they encouraging any illegal activity in my obtaining medical marijuana.

I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal marijuana treatment. I acknowledge that using cannabis as a medicine has been explained to me and that any questions that I have asked have been answered to my complete satisfaction. The physician, staff, and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider. Should an approval be made for my medicinal use of marijuana, I understand that there is a renewal date specified by the physician depending on the condition. I understand that it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval.

Furthermore, the undersigned, or anyone acting on my behalf, hold the physician and his/her principals, agents, and employees, free of and harmless from any liability resulting from the use of medical marijuana.

I further understand that by signing below, I am authorizing the release of any part of this record, except for identifying information, for use in data analysis of medical marijuana treated patients. I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition and attest that I do not intend to use my medical recommendation for the purpose of illegally obtaining, growing or distributing medical marijuana.

By signing below, I acknowledge that I have been offered or provided a copy of the practice’s Notice of Privacy Practices, which explains how my medical information may be used and disclosed, and how I can access this information. I understand that the Notice of Privacy Practices may be updated from time to time, and that I may request a current copy at any time

Authorization for Use/Disclose of Protected Health Information (PHI)

I hereby authorize Holistic Medical Wellness and its designated healthcare providers to use and/or disclose my protected health information (PHI) for purposes of treatment, payment, and healthcare operations, as permitted under the Health Insurance Portability and Accountability Act (HIPAA). This includes the release of my PHI to third parties involved in my care, including laboratories, pharmacies, other healthcare providers, and insurance companies. I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on this consent. I acknowledge that I have received or been offered a copy of the clinic’s Notice of Privacy Practices

Patient Manner of Contact
In general the HIPAA Privacy rule gives individuals the right to request a restriction on uses and disclosures of their PHI. I understand that verbal request is an acceptable authorization for the use of any alternate contact method, number and/or location as well as to change in the manner listed below (i.e. if patient leaves message with contact number and/or location, other than listed below). I understand that Holistic Medical Wellness may call, text, and/or email to confirm appointments at the number I provide and consent unless otherwise directed.

I understand that by signing this form I am confirming my receipt of the Notice of Privacy Practices; authorization for method of contact; and authorization for use and/or disclosure of my PHI.