Statutory Declaration

Name(Required)

First Last

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Do you smoke or vape cannabis?(Required)

How many grams per day do you consume by smoking or vaping?(Required)

Please enter a number from 1 to 100.

How do you smoke or vape cannabis?(Required)

How does smoking or vaping cannabis help you?(Required)

Do you consume cannabis edibles?(Required)

How many grams per day do you consume through edibles?(Required)

Please enter a number from 1 to 100.

How do you consume edibles?(Required)

How does consuming edibles help you?(Required)

Do you consume cannabis tinctures?(Required)

How many grams per day do you consume through tinctures?(Required)

Please enter a number from 1 to 100.

How do you consume tinctures?(Required)

How does consuming tinctures help you?(Required)

The total amount of grams I consume per day is:

Do you want to add any details about how you use medicinal cannabis?

Consent

I agree to the terms and conditions.

My signature further acknowledges that I am fully aware of risks and effects associated with prescribed marijuana use and hereby release the Nurse Practitioner from any and all liability, negligence or other claims arising from my participation in medical marijuana treatment. I shall not now, or at any time in the future, bring any legal claims against the prescribing Nurse Practitioner or any of their affiliates involved in assisting in my treatment using cannabis.

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.


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