You consent to the release of personal health information (PHI) to Green Valley Wellness by way of unsecured email/Skype. You also recognize that other options have been made available to you by way of emailing your personal health information directly to the office of the Physician Specialist/Physician/Nurse Practitioner, to which you have your medical assessment.

You understand that sending personal health information through unsecure email is not necessarily at a high risk of diversion, but this risk is substantially lowered when sending personal health information by way of Email.

You authorise Green Valley Wellness to share your personal health information with the Physician Specialists/Physicians/Nurse Practitioners’ clinic to which you wish to have an assessment and any other parties involved with the process of obtaining your Medical Document.

You understand the purpose for disclosing this personal health information to Green Valley Wellness and you understand that you can refuse to sign this form.

You hereby release Green Valley Wellness, the assessing Physician Specialist/Physician/Nurse Practitioner, his/her clinic, your family Physician and any other involved Physicians/parties from any and all actions, claims, causes of actions, complaints (even by family and friends) and demands for damages, loss, or injury whatsoever arising directly or indirectly as a consequence to your use of medical cannabis and your application to possess and/or produce medical cannabis.

You understand that this Release and Acknowledgement contains valuable information about possessing/cultivating and consuming prescribed medical cannabis and that the assessing Physician Specialist/Physician/Nurse Practitioner requires it to issue a medical document for the Access to Cannabis for Medical Purposes Regulations (ACMPR). You also understand that the consulting Physician Specialist/Physician/Nurse Practitioner will not necessarily be assuming primary care for you, but only be recognized as your ACMPR prescribing Practitioner. You understand and agree to continue to regularly see your primary care Physician for your medical conditions on a regular basis and notify them of your medical use of cannabis.

The Physician Specialist/Physician/Nurse Practitioner will weigh the risks versus the rewards in treating your medical condition(s) and any associated symptoms, with medical cannabis. You confirm that the assessing Physician Specialist/Physician/Nurse Practitioner will be the only practitioner providing a medical document under the ACMPR for the purpose of possessing/cultivating and consuming medical cannabis.

You agree to make no claims or commence any legal action against Green Valley Wellness, the assessing Physician Specialist/Physician/Nurse Practitioner, your family Physician or any other involved Physicians/parties in regards to:

a) Your consumption of medical cannabis from the Licensed Producers or cultivated by yourself.

b) Your Application or medical document(s) for possessing, obtaining, cultivating and consuming medical cannabis.

You are  aware that Physician Specialists/Physicians/Nurse Practitioners generally agree that medical cannabis:

. May affect sight, sounds and touch  

. May impair thinking, problem-solving, coordination, memory and learning  

. May increase heart rate and reduce blood pressure  

. May induce anxiety, fear, distrust, or panic

You are  aware that medical conditions such as schizophrenia, atrial fibrillation, Heart attack/stroke or use of blood thinners may result in a denial for your application to possess and consume medical cannabis. You are  also aware that if pregnant, or planning to become pregnant, that medical cannabis should not be consumed during pregnancy or while breastfeeding.

You are aware that while purchasing your medical cannabis from a Licensed Producer or producing your own medical cannabis is legal,you agree that you will not resell your medical cannabis.

You are aware of the considerable debate and a lack of consensus among Physician Specialists/Physicians/Nurse Practitioners about;

. The appropriate dose and medical use of cannabis  

. The risks of burning medical cannabis as compared to vaporising or ingesting  

. The risks of burning extracted cannabinoids such as oils or hashish  

. The long term psychological and health risks associated with medical cannabis  

. The risk of pulmonary infections and respiratory cancer  

. The risk of triggering mental illness, such as bipolar disorder and schizophrenia  

. The risk of nausea and disorientation

You consent to the disclosure and sharing and use of your personal information and personal health information by way of unsecured Email/Skype, by the assessing Physician Specialist/Physician/Nurse Practitioner, Green Valley Wellness,Your Licensed Producer or any parties involved with the process of obtaining your Medical Document. The information may be used to contact and register the patient. The information may also be used for analytical and research purposes.

You truly believe that treating your personal medical condition(s) with medical cannabis, can potentially, or has had, a positive effect and the benefits outweigh the risks associated.

This is your personal decision to possess and consume medical cannabis and you do not support any claims made by family, friends or other individuals against Green Valley Wellness, the prescribing Physician Specialist/Physician/Nurse Practitioner and any other parties involved with the process of obtaining your Medical Document.

You hereby release Green Valley Wellness, the assessing Physician Specialist/Physician/Nurse Practitioner and any other parties involved with the process of obtaining your Medical Document, from any and all claims, actions, causes of actions, complaints (including friends and family) and demands for damages, loss, or injury arising directly or indirectly to your use of medical cannabis and your application to possess, cultivate or consume medical cannabis.

This release from liability is to be binding on heirs, executors and signs and I acknowledge that you have the right to refuse to sign this form.

If you drive a vehicle on the road or operate machinery, do NOT do so:

1. Within 4 (FOUR) hours of inhaling cannabis vapour or smoke, 
2. Within 6 (SIX) hours of eating or ingesting cannabis edibles or oil, 3. Within 8 (EIGHT) hours of using, if you get euphoric or dizzy – “Stoned” Remember to keep all cannabis products, and medicines, in a Locked Box.