Medical Cannabis Therapy Agreement

In consideration of my receiving orientation and referral services and assessment for medical cannabis, I agree as follows:

Patient Release, Acknowledgement, Indemnity

I understand that this Release and Acknowledgement contains IMPORTANT information about medical cannabis that the assessing physician requires that I acknowledge and understand before he/she may issue an authorization for use of medical cannabis. I further understand that the assessing physician will not be assuming care for me. He/She will, however, assess and evaluate the appropriateness of my request to use medical cannabis to assist in managing the conditions and associated symptoms that I believe; from my own personal experience, medical cannabis to be helpful in managing. I accordingly confirm that the assessing physician will be my medical practitioner for the sole purpose of medical cannabis authorization. I agree not to make any claim or commence any legal proceedings against the assessing physician, his/her practice, my family physician or any other involved physicians (such as specialists) in relation to: a) my use of marijuana as a medicine; and b) my application or authorization for possessing, obtaining and using medical cannabis. I am well aware that physicians generally agree that medical cannabis may: distort my perception (sights, sounds, time, touch); impair my memory and learning; impair my coordination; impair my thinking and problem-solving; increase my heart rate and reduce blood flow; produce anxiety, fear, distrust, or panic.
 I am well aware there is a great lack of consensus among physicians about the appropriate medical use of cannabis; the appropriate dosage for medical cannabis; the risks of smoking medical cannabis as compared to vaporizing or ingesting medical cannabis; the risks of smoking whole plant medical cannabis as compared to extracting the medicinally active cannabinoids and medicating with same; the long-term health and psychological risks associated with the use of medical cannabis;. the degree to which regular consumption of medical cannabis: (a) may contribute to pulmonary infections and respiratory cancer; (b) may damage the cells in the bronchial passages which protect the body against inhaled microorganisms and decrease the ability of the immune cells in the lungs to fight off fungi, bacteria, and tumor cells. For patients with already weakened immune systems, this means an increase in the possibility of dangerous pulmonary infections, including pneumonia; (c) may weaken various natural immune mechanisms, including macrophages and T-cells (d) may trigger attacks of mental illness, such as bipolar (manic-depressive) psychosis and schizophrenia
 I am further well aware that the above listed medical concerns are further compounded by the lack of consistency and uniformity in available medical cannabis products. With conventional drug products I generally consume a medication of a precisely known molecular quantity. I recognize that raw plant Medical Cannabis does not work this way. I appreciate that I will get varying compositions of different cannabinoids and varying proportions of different cannabinoids from strain of plant to strain of plant and even, to a lesser degree, from plant to plant of the same strain. I further appreciate that there is a significant uncertainty regarding the consistency of the medical cannabis drug product I may medicate with which further complicates and compounds the practical issue of medicating with an inconsistent drug product like medical cannabis. I am further aware that ingesting a high dose of medical cannabis can cause nausea and disorientation. 
Despite all these medical concerns, debates and practical issues I honestly believe that for the treatment of my condition(s) and symptom( s) the benefits of medicating with medical cannabis outweigh the risks. 
This is my decision and I also do not support any claims made by my family, friends or other interested parties against said clinic and physicians. 
I hereby release the assessing physician, his/her clinic, my family physician, and any other involved physicians 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 my use of medical cannabis and my Application to Health Canada to possess medical cannabis. 
This release from liability is to be binding on heirs, executors and assigns. I also consent to the disclosure of my personal data by the assessing physician and his/her clinic to Health Canada. 
I understand and acknowledge that while the assessing physician may execute a declaration that I stand to potentially benefit from medical cannabis, the assessing physician will not serve as my primary care physician. As such I agree to seek regular medical care from my primary care physician and that the assessing physician will only deal with assessing his support for my medical cannabis use. I also consent to the assessing physician notifying any specialists who have seen of my decision to use Medical cannabis and I accept any consequences of such notification. 
I agree to notify my primary care physician myself about any license I receive to use cannabis medicinally as cannabis can interact with other medications. If licensed, I agree not to resell any of my medication. I have been advised and understand that a Health Canada license may not prevent police charges nor prevent police and/or local government officials from entering and inspecting my home or place of growing. I agree to check with local bylaws in my area. I also agree that any legal actions will take place in Ontario and be governed by the laws of Ontario, Canada.