I understand that:
The attending physician, staff and/or representatives are neither providing, dispensing nor encouraging me to obtain or
use medical cannabis.
The physician, staff and representatives are addressing specific aspects of my medical care and, unless otherwise
stated, are in no way establishing themselves as my primary care physician/provider.
Should an approval be made for my medicinal use of cannabis, there is a renewal date specified by the physician.
my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval.
I acknowledge that I have not misrepresented any information herein. Any misrepresentation shall lead to termination from
the practice, cancellation of any or all appointments, and forfeiture of any and all fees or payments.
acknowledge that I am not an agent of law enforcement, State or Federal government here for the purpose of
investigation or entrapment.
I acknowledge that I am not recording any portion of my visit.
I acknowledge that my continued approval for medical cannabis use, and the state issued card, is contingent on
reasonable adherence to the regimen given by my clinician. My card may be revoked at any time for inappropriate use
as determined by my clinician or Inhale MD.
I acknowledge that, per policy, all patients will have a limit of 2 ounces per 60 day period placed on the amount of
cannabis that they can purchase. This is to protect patients from predatory sales tactics at dispensaries and to promote
healthful use patterns.
ACKNOWLEDGEMENT OF CANCELATION POLICY
For all new patients we require payment prior to scheduling appointments. Payment is refundable, minus a $100 cancellation fee, up to 2 weeks prior to the appointment. After that, no refund will be issued. If you miss an appointment, or fail to reschedule an appointment prior to 2 business days before your appointment, you will be charged a $100 rescheduling deposit that will be refunded if no payment isdue or applied to any payment due. If you are more that 10 minutes late for an appointment you may be asked to reschedule, subject to a $25 fee. This policy may be updated from time to time and you acknowledge that such changes as reflected on the Inhale MD website shall be final. It is up to you to remain informed of such policies.
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize Inhale MD to disclose and verify my records as a patient to a cannabis dispensary for the purpose
of obtaining cannabis. I understand that this authorization is valid for the period of time for which the recommendation
for cannabis has been issued.
I hereby authorize Inhale MD to disclose my medical records and recommendations to my other health care providers,
without limitation, in accordance with general medical practice and HIPAA.
I hereby authorize the use and disclosure of my patient records, except for personal identifying information, for use
in data analysis of cannabis-treated patients.
I hereby authorize Inhale MD to disclose and verify to law enforcement my patient status should I be arrested or
detained related to my possession or use of cannabis for the purpose of justifying my possession of cannabis. I
understand that this authorization is valid for the period of time for which the recommendation for cannabis has been
I am being evaluated for a physician's certification that I meet the criteria set forth in Massachusetts State law for medical cannabis. The physician will make this certification based, in part, on the medical information I have provided. I have not misrepresented my medical condition in order to obtain this recommendation and it is my intent to use cannabis only as needed for the treatment of my medical condition, not for recreational or non-medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, growing of, sale/purchase and/or distribution of cannabis.
I have been informed of and understand the following:
I must be a Massachusetts resident to obtain an approval of recommendation for the use of cannabis.