I understand the following:
1. All my visits regarding the medical marijuana treatment with Dr. Pedro Oliveros are not covered by and will not be filed with my insurance company per Florida Statues. I understand that no fees associated with care or obtaining medical cannabis can be applied to any insurance plan, according to Florida State law. All fees will be paid by me or my legal representative.
2. I understand that the cost of the initial visit to assess my candidacy for medical marijuana is $200. This includes medical evaluation, certification and order/recommendation (does not include Medical Marijuana Registration Card fee).
3. I understand that Medical Marijuana may affect my blood pressure and heart rate. I agree to monitor my blood pressure regularly while undergoing trial of different strains of cannabis.
4. I agree that the attending physician and his/her principals, agents, and employees, shall not be held responsibility for any harm resulting to me and/or other individuals as a result of my medicinal use of cannabis.
5. I understand that I will not drive while taking high THC cannabis.
6. I understand that the Federal Government’s classifies marijuana as a schedule I controlled substance. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of medical cannabis.
7. (For patients currently taking opioids) I am aware that my current pain management physician may decide to discontinue prescribing my opioids if I am on medical cannabis. Dr. Oliveros is not obligated to take over my opioid management if that happens.
The undersigned hereby consents to the provision of examination/evaluation, treatment, therapies, medical and laboratory procedures, and drugs and supplies by the healthcare providers of Pedro T. Oliveros Jr., MD, and, acknowledges that no guarantee or assurance has been made to the results of such treatments, procedures or examinations.
I represent and affirm that I have read and understand the above and, that the information I have provider is true and correct. It is my understanding that Dr. Pedro Oliveros and his staff are relying on this. I have read the Consent for Treatment and other documents on the following pages and as the patient or patient’s authorized representative or general agent for the purpose of signing this form, I hereby accept its terms.