THIS IS NOT AN APPROVAL FOR THE MEDICAL USE OF CANNABIS
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THIS IS A SIGNATURE FORM ONLY FOR INFORMED MEDICAL CONSENT & VERIFICATION.
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I have received, read and have had my questions answered regarding the WARNINGS, Adverse Effects, Contra-Indications, Risk of Dependency and Risk to Pregnancy of using Cannabis.
This also serves as my signed consent to allow my Health Protected Information to be released, to confirm the validity of this Approval.
I declare that all written and oral information provided to Dr. Courtney or staff is true and accurate and so sign under penalty of perjury.
I understand Dr Courtney is not my primary care clinician and that it is my responsibility to maintain an ongoing relationship with a primary care clinician.
I understand that a renewal approval invalidates all previous older approvals.
I understand that this form is NOT my approval for the medical use of cannabis. My approval will be sent to me separately.
Dr. Courtney is currently traveling and is not available to appear in court in California. Dr Courtney can provide records, declarations and assistance in preparation for trial to an alternate physician expert witness if such becomes necessary.
I Agree to these terms.
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