Release of Liability

I attest that the information on this form is correct and any medical history presented or discussed with the doctor is all factual and complete to the best of my knowledge. I do not plan or intend to use my physician’s recommendation to illegally obtain medical C A N N A B I S. Solely for verification purposes, I authorize The Healing Clinics, LLC to converse internally about my medical condition.

I affirm that I have a debilitating medical condition that negatively affects my quality of life. I have found or am interested in finding out whether or not medical C A N N A B I S provides substantial relief and improvement to my condition.

I understand that the C A N N A B I S plant is not regulated by the United States Food and Drug Administration. Furthermore, I understand the potential risks associated with an elevated daily consumption of medical C A N N A B I S including risks concerning my cardiovascular and pulmonary systems, psychomotor performance, and risks associated with the long-term use of C A N N A B I S, as well as potential drug dependency. I am aware that the benefits and risks associated with the use of C A N N A B I S are not fully understood and that the use of C A N N A B I S may involve risks that have not been identified. In requesting approval or recommendation for the use of medical C A N N A B I S, I assume full responsibility for any risks involved in this action.

I was also advised that the use of medical C A N N A B I S might affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my use of  C A N N A B I S.

Medical Cannabis Declaration

I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition and attest that I do not intend to use my medical recommendation to illegally obtain, grow, or distribute medical C A N N A B I S.

I attest that I am not a member, employee, or agent of any media or law enforcement agency, IF SO, I must disclose that the intent of my participation is not medical. It is illegal to film or record in this office with a video camera, cell phone, or any other recording device be it a still image, video, or audio. This is a direct violation of HIPAA regulations and patient/doctor confidentiality.

I am aware that my recommendation can be revoked at any time and legal actions will be taken if I have perjured or misrepresented myself or my condition, my intentions, or falsified my medical records to the physician.

Additionally, I acknowledge my attending physician and/or attending pharmacist informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical C A N N A B I S The risks, complications, and expected benefits of any recommended treatment, including its likelihood of success or failure, including possibly making an acute or treatable progressive condition or that such will lead to a worsening of the patient’s condition.

I acknowledge my attending physician informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and their risks and benefits. The physician may request that I visit another physician or specialist to further substantiate my condition. I will be informed of all the above-mentioned regardless of whether or not I qualify as a patient.

Termination of Care

I understand that if I violate any of the above conditions, my treatment with controlled substance medications will be terminated immediately, without a 30-day notice.

Potential Drug Interactions Release

I understand that anticoagulants, anti-platelet drugs(including aspirin), herbs, and supplements may reduce blood clotting. C A N N A B I S may change how the body metabolizes these drugs and supplements, possibly increasing the risk of bleeding. I also acknowledge that mixing C A N N A B I S with selective serotonin reuptake inhibitors, or other anti-depressants/anti-psychotics may increase the risk of mania or psychotic features.

Please consult directly with your specialist to monitor drug effectiveness and potential side effects closely. I have read and understand the information provided regarding Potential Drug Interactions with C A N N A B I S, have discussed it with my physician/healthcare provider, and have had all questions answered to my satisfaction.

Acknowledgment of Privacy Notice

I have been informed of the practice’s Notice of Privacy Practices. The notice provides, in detail, the uses and disclosures of my PHI (Protected Health Information)that may be made by this practice. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all PHI at or controlled by this practice. I understand I can obtain this practice’s Notice of Privacy on request.

HIPAA Notice of Privacy Practices Acknowledgement of Receipt

By my signature below, I hereby acknowledge that I have read and understand the privacy practice notice and may obtain additional copies upon my request.

Patient Acknowledgement and Agreement

I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medical C A N N A B I S treatment. I acknowledge that using C A N N A B I S as a medicine has been explained to me and representatives are addressing specific aspects of my medical care and are in no way establishing themselves as a primary care provider. Should an approval be made for my medicinal use of C A N N A B I S, I understand that there is a renewal date specified by the physician depending on the condition. I understand that it is my responsibility to see the physician to assess the possible continuance of C A N N A B I S use beyond the terms of the approval.

Patient Manner of Contact

I understand that this practice calls, texts, and emails to confirm appointments at the number and email address I provide.

I understand that medical C A N N A B I S is a medicine used to treat the suffering caused by serious and debilitating medical conditions.

I have been advised that the use of medical C A N N A B I S may affect my coordination, motor skills, and cognition in ways that could impair my ability to drive and agree NOT to operate heavy machinery, drive, or engage in potentially hazardous activities.

I understand that adverse effects may occur while I am taking medical C A N N A B I S. Adverse effects of medical C A N N A B I S may include but are not limited to euphoria, difficulty in completing complex tasks, low blood pressure, sedation, dysphoria, alterations in the perception of time and space, dizziness, anxiety, confusion, impairment to short term memory, inability to concentrate, suppression of the body’s immune system, impairment of motor skills, delayed reaction time, loss of physical coordination, paranoia, and increased eating.

I understand that some patients may become dependent on C A N N A B I S. This means they experience withdrawal symptoms when they stop using C A N N A B I S. Signs of withdrawal symptoms may include feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.

I understand it may be classified as a felony to have C A N N A B I S while armed with a firearm.

I understand that although C A N N A B I S does not produce a specific psychosis, it may exacerbate schizophrenia in persons predisposed to that disorder.

I agree to tell my attending physician if I have ever had symptoms of depression, been psychotic, attempted suicide, or had any other mental problems. I also agree to tell my attending physician if I have ever been prescribed or taken medicine for any of the conditions stated above. Furthermore, I understand that my attending physician does not suggest nor condone that I cease treatment and or medication that stabilizes my mental or physical conditions.

FURTHERMORE, I UNDERSTAND that my attending physician DOES NOT treat any mental health issues and that I must seek treatment elsewhere for any Mental Health conditions I am experiencing.

I understand there are few known interactions between C A N N A B I S and medications other than herbs. However, very few interactions between herbs and medications have been studied. I agree to tell my attending physician if I am using any herbs, supplements, or other medications.

I am aware that a Notice of Compliance has not been issued under the Food and Drug Regulations concerning the safety and effectiveness of C A N N A B I S as a medicinal drug. I understand the significance of this fact.

I am aware that medical C A N N A B I S has not been approved under the Federal Regulations and I understand that medical C A N N A B I S has not been deemed legal under federal law.

I understand some users might develop a tolerance to C A N N A B I S. This means higher and higher doses are required to achieve the same benefit. It is recommended for patients to have an intermission with the drug periodically or as recommended by my physician. If I think I may be developing a tolerance to C A N N A B I S, I will notify my attending physician.

I understand the benefits and risks associated with the use of C A N N A B I S are not fully understood and that the use of C A N N A B I S may involve risks that have not been identified. I accept such risk.

I understand that if respiratory problems or other ill effects experienced in association with the use of medical C A N N A B I S appear, I agree to discontinue its use and report any such problems or effects to my attending primary care physician.

I understand C A N N A B I S varies in potency. The effects of C A N N A B I S may also vary with the delivery method. Estimating the proper C A N N A B I S dosage is very important. Symptoms of C A N N A B I S overdose include, but are not limited to nausea, vomiting, hacking cough, heart rhythm disturbances, numbness in the limbs, anxiety attacks, and incapacitation.

If I start taking medical C A N N A B I S, I agree to tell my attending physician if I start to feel sad or have crying spells, lose interest in my normal activities, have changes in my normal sleeping patterns, become more irritable than usual, lose my appetite, become unusually tired, withdraw from family and friends, or any other side effect that is not to your liking and out of your normal behavior.

I agree that, if I am a female patient, I will contact my attending physician if I become or am thinking about becoming pregnant. I acknowledge that the use of medical C A N N A B I S potentially creates pass-through problems for a fetus during pregnancy and to a baby during breastfeeding.

I understand that using C A N N A B I S while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and C A N N A B I S.

I understand that I should not be driving a vehicle while using C A N N A B I S and that I can get a DUI for driving under the influence.

Medical C A N N A B I S is not regulated by the USFDA and therefore may contain unknown quantities of active ingredients, impurities, and or contaminants.

I am not permitted to use medical C A N N A B I S within 1,000 feet of any daycare or school. If I reside near those institutions, I must use my medicine within the privacy of my own home. C A N N A B I S , In ANY form, is NOT allowed on any active U.S. Military base by either active duty military or their families.. If you are an active duty military personnel, you must confirm with your commanding officer to determine if  C A N N A B I S is or is not an approved medication.

I agree to follow up with my attending physician at The Healing Clinics, LLC with supporting medical records pertaining to my medical conditions, if required.

I understand my attending physician, staff, and/or representatives of The Healing Clinics, LLC are neither providing or dispensing medical C A N N A B I S. I also acknowledge that my attending physician, staff, and/or representatives will NOT be providing or discussing information regarding for any alternative means to obtain C A N N A B I S.

I certify that I have read this document and declare under penalty of perjury that the information contained herein is true, correct, and complete. I acknowledge that any manipulation, alteration, or falsification of this form, the letter of recommendation will result in the immediate termination of any legal right to my use of medical C A N N A B I S. Furthermore, the above-mentioned activities will be reported to the appropriate local authorities.

Traveling with Medicinal  M A R I J U A N A

I understand that I am to consult TSA rules or an Attorney in regards to airway travel with medicinal C A N N A B I S. I understand that I am to consult with a cruise line consultant or an Attorney in regards to ocean/waterway travel with medicinal C A N N A B I S. I also understand that it is ILLEGAL to transport medical C A N N A B I S that has been recommended for me in Louisiana, across the state lines of Louisiana.

Treatment Goals

I understand that the main treatment goal is to improve the quality of my life. This includes the ability to function and/or work. In consideration of this goal, and because I am being given a potent medication to help me reach my goal, I agree to help myself by following better health habits. I must also comply with the treatment plan as recommended by my physician. I understand that a successful outcome of my treatment may be enhanced by following a healthy lifestyle.

Patient Responsibility

The patient understands and voluntarily agrees that:

• I understand that operating a motor vehicle may not be allowed while taking controlled substance medications and that it is my responsibility to comply with the laws of the State of Louisiana and/or the State in which I am traveling while taking the recommended medications.
• I understand that I must maintain a primary care physician while being cared for in this clinic. My primary care physician monitors my Louisiana Prescription Monitoring Program and therefore will be aware of my medical M A R I J U A N A use and my PCP determines the appropriateness of treating my qualifying condition with medical M A R I J U A N A and any potential interactions of medical M A R I J U A N A with my current medical treatment provided by my PCP. The aforementioned physician will be used to care for my medical needs, and we may coordinate care with your physician.
• As part of our Diversion Control Program, patients may be asked to take a urine drug screening.
• It is my responsibility to inform my primary care physician and/or Pain Management Physician of my enrollment at The Healing Clinics, LLC, and that my physician here at The Healing Clinics, LLC may coordinate care with that physician as necessary to my treatment here at The Healing Clinics, LLC.
• In case of emergency, I will call 9-1-1

Risks of the Therapeutic Use of  C A N N A B I S

I understand that there are potential risks involved with both the therapeutic use of C A N N A B I S and alternative conventional treatment options. Caution should be taken against driving, operating machinery, or performing any task that requires the patient to be alert or react when under the influence of the drug.

Medication must be stored in a secured location to reduce the risk of exposure to children, pets, or diversion by others. Therapeutic C A N N A B I S has not yet been approved by the USFDA for the treatment of debilitating medical conditions and possession may be viewed as illegal under federal law, and subject to federal (and workplace) enforcement action.

The Healing Clinics, LLC offers telemedicine as a means of contact between the patient and their medical doctor using technology. This telemedicine application begins with the consent of the Patient.

I, , consent to Telemedicine as facilitated by The Healing Clinics, LLC. 

1. I understand that I may choose to decline telemedicine-facilitated medical services at any time and may withdraw from telemedicine care at any time. To decline or cancel the use of telemedicine, I will call 318-227-4088 and inform The Healing Clinics, LLC staff that would like to decline telemedicine or cancel my use of telemedicine if I am currently enrolled in the program.
2. If you choose to withdraw your consent for telemedicine, it will not affect your right to future care, treatment, benefits, or programs to which you are otherwise entitled. Alternative methods of care may be available
3. I am aware that in using technology, any equipment failure may result in:

• Delayed Care
• Poor image and/or audio quality
• Telemedicine Network and Software security protocols which protect the confidentiality of your medical information could fail, causing personal information to be inappropriately revealed.

1. I understand that I must maintain a primary care physician while being cared for in this clinic and the aforementioned physician will be used to care for my other medical needs.
2. The Healing Clinics, LLC physician’s role in patient care is to guide patients to a better quality of life with a treatment plan based on therapeutic C A N N A B I S. To do so, the clinic(s) will help in establishing the patients qualifying condition(s) through medical records, patient evaluations. Each physician must have a consultation with the patient either in person or by telemedicine to thoroughly understand the needs of each patient. No audio or video will be recorded from this consultation.
3. Your Telemedicine Physician is any physician on staff at The Healing Clinics, LLC as listed in your treatment plan. The Physician's specialty is Therapeutic C A N N A B I S for this visit.
4. For follow-up appointments, copies of your medical records, or technical questions in case of equipment failure during the consultation, or to contact your physician please contact The Healing Clinics, LLC headquarters of Shreveport, LA at 318-227-4088 or info@thehealingclinics.com and The Healing Clinics, LLC staff will help assist you.
5. In case of an emergency, please dial 9-1-1 or have someone dial 9-1-1 for you if you are unable to do so.
6. Others may be physically present with you or with the remote specialist to operate equipment or assist with evaluation, examination, and/or treatment. Some parts of the exam involving physical tests may be conducted by individuals at your location at the direction of the telemedicine physician.
7. Telemedicine is intended to improve your access to specialized medical care by enabling you to be evaluated by a specialist at a remote or distant location. If you experience an emergency during the telemedicine visit, you understand that the remote specialist will arrange for follow-up care through a local physician or healthcare provider. The remote specialist’s responsibilities will then end upon the termination of the telemedicine connection.
8. Attached to this document package you will also find your Privacy Notice outlining your HIPAA rights.

I have read and understand the information provided regarding Telemedicine, have discussed it with my physician/healthcare provider, and have had all questions answered to my satisfaction.

IT HAS BEEN MADE CLEAR THAT THE PHYSICIANS, STAFF, AND REPRESENTATIVES OF THIS CLINIC ARE NOT PROVIDING

MEDICAL  C A N N A B I S , NOR ARE THEY ENCOURAGING ANY ILLEGAL ACTIVITY IN MY OBTAINING MEDICAL  C A N N A B I S.

I HAVE READ THIS CONTRACT AND PATIENT IN-TAKE FORM COMPLETELY, AS INDICATED BY MY INITIALS AND SIGNATURE

BELOW. ALL MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I AGREE TO COMPLY FULLY WITH THIS CONTRACT. IN ADDITION, I FULLY ACCEPT THE CONSEQUENCES OF VIOLATING THIS AGREEMENT.

BY MY SIGNATURE ON THIS DOCUMENT I AM ACKNOWLEDGING THAT THE PHYSICIANS, STAFF, AND REPRESENTATIVES OF THE HEALING CLINICS, LLC ARE ADDRESSING SPECIFIC ASPECTS OF MY MEDICAL CARE, THAT BEING MEDICAL  M A R I J U A N A ONLY, AND, UNLESS OTHERWISE STATED, ARE IN NO WAY ESTABLISHING THEMSELVES AS MY PRIMARY CARE PHYSICIAN OR PROVIDER. FURTHERMORE, THE UNDERSIGNED, MY HEIRS, ASSIGNEES, OR ANYONE ELSE ACTING ON MY BEHALF, HOLD THE PHYSICIANS AND HIS/HER PRINCIPALS, AGENTS, AND EMPLOYEES OF THE HEALING CLINICS LLC AND THE HEALING CLINICS LLC, FREE OF AND HARMLESS FROM ANY RESPONSIBILITY FOR ANY HARM RESULTING TO ME AND/OR OTHER INDIVIDUALS AS A RESULT OF MY MEDICAL MARJIUANA USE.

I accept an electronic signature if I am unable to provide my signature.

Please take a moment and verify all information below is correct, then sign and submit.

The Healing Clinics is pleased to offer you an autopay option for today's recommendation and for your renewal for next year. This is not activated without your approval. To do so, after completing these forms, wait for the autopayment screen to appear and select the "Recurring Billing" radio button at the top left of the screen. If at any time you wish to cancel this scheduled auto-renewal, simply contact your credit card company. *Please note: You do not have to autopay or select this option to qualify today or for renewal*