PATIENT ACKNOWLEDGEMENT

& RELEASE OF LIABILITY

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By signing this document, I acknowledge and agree that:

1. There are risks from the use of marijuana for medicinal and recreational purposes, and these risks can be significant, including the potential for serious health problems and death, and while there may be benefits from the use of marijuana for medicinal/therapeutic purposes, the risks do exist; and,

2. I, for myself and on behalf of my heirs, assigns, personal representatives, family, and next of kin, knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases or others, and assume full responsibility for my use of marijuana and/or participation in the Michigan Medical Marijuana Program (hereafter, MMMP); and,

3. Green Spirit Clinic PLLC (hereafter, GSC) physician(s) are not providing me with a “prescription” for medical marijuana, nor are they encouraging my use of marijuana for medical or recreational purposes.  I understand that my GSC physician(s) is simply stating their medical opinion as to whether or not my medical history meets the definition of a “qualifying medical condition” as defined by the Michigan Medical Marijuana Act.

4. I have been advised by GSC of the risks and benefits of the medicinal use of marijuana and have reviewed and understand the “Risks & Benefits Statement” provided by GSC.

5. I, for myself and on behalf of my heirs, assigns, personal representatives, family members, and next of kin, hereby agree to waive, release, covenant not to sue, discharge and hold harmless GSC, their directors, agents, attorneys, volunteers, insurers, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable , owners and lessors of the premises used to conduct business, with respect to any claims for and all injury, illness, disability, death, or loss or damage to person or property, including any damages, losses, or liabilities related thereto, whether arising from the negligence of the releasees or otherwise, now and forever, from my use of medical marijuana and/or participation in the MMMP.

 

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT FULLY UNDERSTAND ITS TERMS, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

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PLEASE PRINT AND SIGN YOUR NAME BELOW, THEN PRESS SUBMIT.