Appointment Agreement

Please read this Agreement in its entirety, sign, and date.

Forms of Medical Marijuana and Side Effects

FORMS OF MEDICAL MARIJUANA

Forms of medical marijuana that may be dispensed to patients with a medical recommendation:

• Oils
• Tinctures
• Plant Material
• Edibles
• Patches
• Suppositories

With respect to the methods of using medical marijuana, all the following apply:

• The smoking or combustion of medical marijuana is prohibited.
• Vaporization of medical marijuana is permitted.

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SIDE EFFECTS

Medical marijuana affects each person differently, but you may experience one or more of the any of these side effects:

• Anxiety and Uneasiness
• Paranoia
• Thirst and Dry Mouth
• Hunger
• Insomnia
• Red Eyes
• Short-Term Memory Loss
• Heightened Sensory Perception
• Drowsiness and Impaired Judgement
• Respiratory Issues
• Giddiness
• Tolerance Fatigue
• Slower Reaction Time
• Diarrhea
• Increased Heart Rate
• Constipation
• Impaired Balance
• Hallucinations
• Fainting
• Dizziness
• Urinary Retention
• Slurred Speech
• Dependency
• Dry Mouth (Cotton Mouth)
• Red Eye

Side effects can vary from one individual to another. Some may experience one or more of the above side effects while others may have none or others not listed. Some reactions such as anxiety, panic or paranoia may occur if you take too much marijuana, or you are an inexperienced user. Small amounts of THC can have calming effects and relieve anxiety while larger doses for some users may bring mild to intense angst, even panic. Factors that may increase the risk of anxiety or paranoia: your personality, your genetics, or already having an anxiety disorder.

Insomnia

Even though weed is known more for producing sedative effects, you may find yourself struggling with insomnia after using. Here are some things to try:

• Avoiding coffee, tea or other beverages containing caffeine. If you must have your cup of coffee, have it in the morning, not in the late afternoon or at night.
• Exercising. Avoid exercise at least a few hours before it’s time for you to go to bed.
• Not napping during the day.
• Relaxing. Try relaxing activities a half-hour before bedtime.

Memory

Chronic users, may have more potential of forgetting words they just read than non-users. Here are some things you can do if you have a short-term memory impact when you take marijuana.

• Take Omega-3 fatty acids.
• Get plenty of exercise.
• Take B vitamins.
• Get plenty of sleep.
• Practice mental exercises like repetitive memory games.
• Try white willow bark.
• Eat healthily.

Drowsiness and Impaired Judgment

1. Marijuana could cause drowsiness, dizziness and impaired judgment. Don’t operate machinery, drive or perform any other hazardous activities while you’re using your medical marijuana treatment.
2. Don’t take any other medications known to cause drowsiness while using marijuana, like antidepressants, sedatives, antihistamines, anxiety medications, muscle relaxants and pain relievers.
3. Don’t drink alcohol after using medical pot. Alcohol increases drowsiness, dizziness and impaired judgment.

Respiratory Issues

Smoking marijuana may cause some of the same respiratory issues tobacco smokers experience, such as having phlegm production and a daily cough. They may also get acute chest illnesses, such as bronchitis, more frequently. Below are other methods of use if you experience these common respiratory issues.

• Edibles
• Vaporizers
• Tinctures
• Oils
• Raw marijuana

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OHIO MEDICAL MARIJUANA RULES AND REGULATIONS

As of September 8, 2016, it is legal for Ohio Residents with certain medical conditions to use non-smoking forms of medical marijuana when recommended by an eligible certified physician. Once the law is fully effective, eligible patients will be able to obtain medical marijuana at state-licensed dispensaries.

What forms of medical marijuana are permitted in Ohio?

• Oils
• Edibles
• Inhalation of marijuana through vaporizer (not direct smoking)
• Any other forms approved by the State Board of Pharmacy
• Tinctures
• Patches

No vaporizing device, the design of which places medical marijuana in direct contact with the device’s heating element, may be used to vaporize the resin contained within, or an extract of, medical marijuana. Vaporizing devices shall not be capable of being heated to temperatures at which medical marijuana plant material will burn.

What else do I need to know about the medical marijuana law?

1. The law prohibits smoking medical marijuana or growing it at home.
2. Recreational use of marijuana is still illegal in Ohio.
3. Patients wanting to use medical marijuana must apply to the State Board of Pharmacy for registration card. The application must be submitted on their behalf by a physician approved by the Ohio State Medical Board who possesses a certificate to recommend medical marijuana. The application must show that the patient has been diagnosed with qualifying medical condition and that a physician-patient relationship exists.
4. There are significant long- and short-term risks of marijuana use, including with medical marijuana. You should speak with your physician to understand both the risks and the possible benefits of medical marijuana for you.
5. Even if medical marijuana was recommended by a doctor, a new Ohio law does not prevent employers from taking action if an employee violates the company’s drug policy against marijuana use.

A. A patient and patient’s caregiver(s) may collectively purchase no less than a whole day unit at a single time. A whole day unit shall equal the following amounts of each form of medical marijuana:

• One-tenth of an ounce (two and eight-three hundredths’ grams) of plant material
• Two-hundred ninety-five milligrams of THC contained in a patch, lotion, cream, or ointment
• One hundred ten milligrams of THC contained in an oil, tincture, capsule, or edible for administration
• Five hundred ninety milligrams of THC contained in oil for vaporization

B. A patient and patient’s caregiver(s) may collectively purchase, within a ninety-day period, no more than a ninety-day supply. A ninety-day supply may consist of multiple forms of medical marijuana, but the total ninety-day supply shall not exceed a ninety-day supply whether purchased as a single form of aggregated across forms. A ninety-day supply is defined by plant material form as follows:

• No more than eight ounces (two hundred twenty-six and eight-tenths grams) of tier I medical marijuana
• No more than five and three-tenths ounces (one hundred fifty an three-tenths grams) of tier II medical marijuana
• No more than twenty-six and fifty-five-hundredths grams of THC content in patches for transdermal administration or lotions, creams, or ointments for topical administration
• No more than nine and nine-tenths grams of THC content in oil, tincture, capsule, or edible from for oral administration
• No more than fifty-three and one-tenths grams of THC content in medical marijuana oil for vaporization

C. Notwithstanding paragraphs (A) and (B) of this rule, a patient who is diagnosed with a terminal illness and patient’s caregivers may collectively purchase, within a ninety-day period, no more than a ninety-day supply. A ninety-day supply may consist of multiple forms of medical marijuana, but the total ninety-day supply shall not exceed a ninety-day supply whether purchased as a single form or aggregated across forms. A ninety-day supply is defined by plant material form as follows:

• No more than ten ounces (two hundred eighty-three and five-tenths grams) of tier I medical marijuana
• No more than thirty-three and three-tenths grams of THC content in patches for transdermal administration of lotions, creams, or ointments for topical administration
• No more than eleven and seven-tenths grams of THC content in oil, tincture, capsule, or edible form for oral administration
• No more than sixty-five and seven-tenths grams of THC content in medical marijuana oil for vaporization

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OHIO MEDICAL MARIJUANA RECOMMENDATION PATIENT AGREEMENT

Please read the following statements below relating to the use of medical marijuana. Do not sign this agreement if you have questions or do not understand the information below.

Acknowledgement of Disclosure and Informed Consent

• I understand that I will be evaluated by a physician who recommends medical marijuana for treatment of my qualifying medical condition. My medical records have been provided and I attest that I have not misrepresented my medical condition. I intend to use medical marijuana as directed by the recommending physician and not for recreational or non-medical use.
• I understand side effects, from the use of medical marijuana, may include but are not limited to the following: memory loss, irregular heartbeat, slower reactions, inability to concentrate, shortness of breath, impaired vision, low blood pressure, paranoia, increased cancer risk, tachycardia, birth defects, schizophrenia, bipolar disorder, anxiety, confusion, headache, nausea, vomiting, hunger, and loss of appetite.
• I understand consuming alcohol is not recommended when using medical marijuana.
• I understand marijuana can have potential effects on my coordination, motor skills and cognition. I acknowledge that I should not drive, operate heavy machinery or engage in potentially hazardous activities that may endanger myself or others.
• I understand pregnant women, women planning on becoming pregnant and breastfeeding women should not use medical marijuana products.
• I understand that smoking marijuana is not permitted under Ohio Law. I understand it may be hazardous to my health due to carcinogens that increase my risk of cancer, tachycardia, hypertension, heart attack, birth defects, brain damage and lung disease.
• I understand medical marijuana has not been approved by the Food and Drug Administration for marketing as a drug. This means that the “manufacture” of marijuana for medical use is not subject to any federal standards or quality control. Marijuana may contain unknown quantities of active ingredients varying in potency, impurities, contaminants and substances.
• I understand there is a possibility of developing a tolerance to, dependence on, or addiction to marijuana.
• I understand my information will be sent to the Ohio Medical Marijuana Control Program and the Ohio State Board of Pharmacy.

Patient Attestation

• I will comply with the State of Ohio Medical Marijuana control Program’s conditions, terms and regulations as set forth in Chapter 2925 and 3796 of the Revised Code and Chapter 3796 of the Administrative Code.
• I understand the purpose for the medical marijuana recommendation is to treat my qualifying medical condition. I will not resell, distribute or manufacture marijuana.
• I am not pregnant or breastfeeding.
• I will notify the physician if I experience any of the following side effects: sadness, loss of appetite, sleeplessness or insomnia, irritability or withdrawal. I will notify the physician if I become pregnant.
• I agree to call 911 immediately with any severe adverse reactions when using medical marijuana.

Release of Liability

I acknowledge that AccuDoc Inc PC (dba”AccuDoc Medical Marijuana Doctor” “AMMJD”) and its employees are not my primary care provider. I fully accept responsibility and assume the risks and side effects associated with the use of medical marijuana. Therefore, I, or anyone acting on my behalf, hold AccuDoc Inc PC (dba “AMMJD”) and its principals, agents, employees, assigns and contractors free of and harmless from any responsibility for any harm resulting to me and or other individuals due to my use of medical marijuana.

4731.30 Ohio Certificate to Recommend Medical Use of Marijuana

(H) A physician is immune from civil liability, is not subject to professional disciplinary action by the state medical board or state board of pharmacy, and is not subject to criminal prosecution for any of the following actions:

• Advising a patient, patient representative, or caregiver about the benefits and risks of medical marijuana to treat a qualifying medical condition
• Recommending that a patient use medical marijuana to treat or alleviate the condition.
• Monitoring a patient’s treatment with medical marijuana.

I acknowledge that my visits with the physician at AccuDoc Inc PC (dba “AMMJD) are limited in scope to the above immune actions. Any additional advice or topics discussed should be construed as adjunctive advice related to increasing the effectiveness of and/or monitoring treatment with medical marijuana. I agree to waive liability related to any visits or interactions with the physician at AccuDoc Inc PC (dba “AMMJD”).

I, the undersigned, or anyone acting on my behalf, hold the physician at AccuDoc Inc PC (dba “AMMJD”) and its principals, agents, assigns, employees and contractors free of and harmless from any liability relating to any interactions with the physician. This release of liability is binding upon me, my heirs, assigns and caregivers.

I certify that I have read and understand this document and declare under the penalties of perjury that the information contained herein is true, accurate and complete.

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OHIO MEDICAL MARIJUANA PAYMENT POLICY

• AccuDoc Inc PC (dba “AccuDoc Medical Marijuana Doctor” “AMMJD”) requires an annual upfront evaluation fee that covers the non-refundable initial evaluation which is required by the state of Ohio for a patient to remain active on the patient registry.
• The annual fee for all services provided is $149.00. (Veterans is $129.00 and proof of military service is required.)
• All MMJ renewals are $99.00.
• Appointments may be rescheduled one time with a 48-hour notice. Without proper notice of cancellation, the initial non-refundable fee will NOT apply to a rescheduled visit.
• * “AUC” reserves the right to issue refunds at our discretion*
• The Ohio Board of Pharmacy requires a $50.00 (Veterans $25.00) annual fee which is not included in the $169.00 (or Veterans $149.00) annual fee at “AMMJD”.
• No refunds will be issued to patients who lose access to medical dispensaries due to violation of the Ohio’s Medical Marijuana Control Program.
• No form of insurance will be accepted (including Medicare and Medicaid). All payments due must be by cash, credit, or debit.