1. The purpose of my visit to Midwest GreenCert is for a consultation with the attending physician and the evaluation of my medical history and medical records which I have brought with me or have had sent to Midwest GreenCert. This consultation and medical record review, I believe, should allow the attending physician at Midwest GreenCert to determine if I qualify for a Medical Marijuana (“MMJ”) card to be issued by the Missouri Department of Health and Senior Services (“MDHSS”) for the medical use of marijuana pursuant to Missouri laws and regulations.
2. I consider my medical condition to be debilitating and that this condition is progressing to an extent that one or more my major life activities are substantially limited.
3. My attending physician, staff, agents and/or representatives of Midwest GreenCert are (i) not providing, dispensing, nor encouraging me to obtain or secure medical marijuana, and (II) are not
providing information regarding dispensaries, treatment centers, or any other methods of obtaining or securing medical marijuana.
4. I understand that once the attending physician at Midwest GreenCert issues a Physician Certification Form, the final decision for the issuance of an MMJ card will rest with the MDHSS. I may be denied a card from the MDHSS. Should I be able to obtain an MMJ card, there shall be an expiration date specified by DPH. It is entirely my responsibility to see an attending physician at Midwest GreenCert to assess the possible continuance of medical marijuana use beyond the expiration date of MMJ card issued by the MDHSS. When under the influence and/or in possession of cannabis in public, the MMJ card shall be on my person at all times, if I am issued one.
5. My attending physician or the staff at Midwest GreenCert is addressing specific aspects of my medical care and, unless otherwise stated in writing, is in no way whatsoever establishing themselves as
my primary care or primary specialty care physician or health care provider. All medical information that I have provided is accurate.
6. I acknowledge that Midwest GreenCert informed me that MMJ is an alternative to the recommended treatment, including no treatment, and has informed me of the risks and benefits. I acknowledge that I have received and reviewed a copy of a Midwest GreenCert form entitled “Medical Marijuana Benefits and Risks”. I further acknowledge that I am aware and have been advised of the potential side effects and risks of the short term and long term use of medical marijuana. I have had the opportunity to discuss all matters that I wished to discuss
related to the use of medical marijuana with the attending physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified.
7. I acknowledge that the federal government has classified marijuana as a Schedule I controlled substance having a high potential for abuse, with no accepted medical use and a lack of accepted safety for use under medical
supervision. Federal law prohibits the manufacture, distribution and possession of marijuana even in states, such as Missouri, which have modified their state laws to treat marijuana as a medicine. Furthermore, marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore the “manufacture”
of marijuana for medical use is not subject to any standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients, can vary in potency, impurities, contaminants, and substances in addition to medically active components.
8. I have reviewed the privacy policies on the website of Midwest GreenCert and understand that no confidential information will be released without my consent unless required by the due process of law. I do, however, authorize Midwest GreenCert to reveal my medical condition with the requisite government or licensed
9. I understand that using marijuana while under the influence of alcohol is not recommended under any circumstances. I shall under no circumstances drive a car or operate machinery while under the influence of medical marijuana. I understand that if I am stopped by a traffic control officer, I can be arrested for the offense of “Driving under the Influence” (“DUI”). Cannabis will be treated as would an open container of alcohol. It will not be within reach in the car, and will not be used or extinguished in the vehicles ash tray.
10. I acknowledge that I will not smoke cannabis with 1000 feet of a school or day care center. I shall primarily use medical marijuana in privacy.
11. I understand that MMJ is self-medication and further agree that if I elect to use medical marijuana I will use it strictly for the treatment of my authorized medical condition and will be at my sole discretion. If I elect to use medical marijuana, I hold Midwest GreenCert and its staff and agents free of and harmless from any
responsibility for any harm resulting to me or others as a result of my use. I further acknowledge that the MDHSS issued MMJ card is not a Prescription and my use of medical marijuana is entirely my responsibility and
is my voluntary act.
12. I agree to immediately cease using medical marijuana and to contact Midwest GreenCert if I experience any side effects. I will also contact Midwest GreenCert if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends. If the symptoms are acute, I will call 911 to obtain emergency medical care.
13. I acknowledge that the office visit, review of my records, and the issuance of a Physician Certification Form by Midwest GreenCert, and any Application to the MDHSS is or may be subject to published fees that are not
covered by health insurance. I agree to pay the latest published fees at the time of my appointment. If I require and request a renewal of my MMJ Card I will pay the fees published at that time.
14. I am not on probation or have legal matters pending for a drug or marijuana related offense.
15. I acknowledge that I am not an agent of law enforcement, for the local, state or federal government and here for the purpose of investigation or entrapment. I acknowledge that I am not a member of the media or press and that all communication is strictly confidential. I acknowledge that I am not recording any portion of my visit with Midwest GreenCert nor do I possess any recording equipment. I understand Midwest GreenCert does not approve such action.
16. I hereby authorize Midwest GreenCert to verify my patient status to recognized legal authorities should I be detained by such authorities related to my possession or use of medical marijuana.
17. (Females only) If I am of child bearing age and become pregnant, I will discontinue use as continued use may be detrimental to the fetus.