Forms of Program Identification
Designated Caregiver Information (if applicable)
(A Designated Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary. If you feel that you need a caregiver, please contact your certifying physician.)
I understand that it is unlawful to use and possess medical marijuana outside of the State of New York. I further understand that my Medical Marijuana Program Registry ID Card does not allow me to cultivate marijuana for any purpose.
I agree that I will not divert any marijuana to any other person. All medical marijuana I purchase will be for my sole consumption.
I agree to use medical marijuana in a manner that fully comports with all relevant New York State laws and regulations, and hereby release and waive all claims against Citiva Medical, LLC d/b/a Be. from any and all liability related to my use of medical marijuana.
Please do not sign this agreement if you do not understand the information you have received or are not comfortable with the risks that may be related to the medical use of cannabis.