Medicinal Marijuana Acknowledgement of Disclosure and Informed Consent

I understand that side effects may occur while I am taking medical marijuana. Side effects of medical marijuana can include, but are not limited to:

Unpleasant change on mood/sensation, lethargy, nausea, problem with memory, confusion, headache, anxiety, paranoia, loss of coordination, palpitations, psychological dependence on cannabis.

I acknowledge that I have been advised not to drive vehicles, operate machinery, or participate in any activity that requires safe judgment or analytical abilities while under the influence of cannabis. Although marijuana does not produce a specific psychosis, the possibility exists that it may exacerbate schizophrenia in persons predisposed to that disorder. I understand that using marijuana while under the influence of alcohol is not recommended.

I understand that the doctors of MedRxC are not my primary care physicians; they will not assume any role beyond counseling and issuing an approval/recommendation if they believe one is indicated. Monitoring and supervision of my health care is my own responsibility in conjunction with my personal physician and or other health care provider.

Arbitration agreement and informed consent

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract or were unnecessary or unauthorized or were improperly, negligently or incompetently rendered; Will be determined by submission to arbitration as provided by California law, and not buy a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, entering into it, are giving up their constitutional right to have ay Such dispute decided in court of law before a jury, and instead are excepting the use of arbitration.

Article 2: All Claims Must Be Arbitrated: it is the intention of the parties that this agreement bind all parties who’s claims may arise out of or relate to treatment or services provided by the healthcare provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the healthcare provider and/or other licensed healthcare providers preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as a back up for the healthcare provider, including those working at the healthcare providers clinic or office or any other clinic or office whether signatories to this

form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the healthcare provider, and/or the healthcare providers associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, Claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the healthcare provider to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against the healthcare provider; any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures And Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within 30 days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirds days thereafter. The neutral arbitrator shall be the sole arbitrator and shall decide the arbitration. Each part to the arbitration shall pay such parties pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit.

Either parties shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of the California Medical Injury Compensation Reform Act shall apply to disputes within this arbitration agreement, including, but not limited to, sections establishing the right to introduce evidence of any amount payable as a benefit to the patient as allowed by (Civil Code 3333.1) The limitation on recovery for non-economic losses (Civil Code 3333.2), and the right to have a judgment for future damages conformed to periodic payments (CCCP 667.7). The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.

NOTICE: by signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. See article 1 of this contract.