Medical cannabis informed consent · Alternative Health MD

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Patient

First name *

Last name *

Date of birth *

Phone *

Certification

I understand an evaluation does not guarantee certification. If Dr. Ewals certifies me, the state still reviews my application and decides on my card. *

Risks

I understand cannabis can be habit-forming. Cannabis use disorder is possible, and the risk is higher with frequent use and high-THC products. *

I understand cannabis can cause side effects, such as drowsiness, dizziness, anxiety, and trouble with memory or focus. *

I will not drive or operate machinery while impaired by cannabis, and I'll take care with safety-sensitive work. *

I have told Dr. Ewals about all my medicines and supplements, and I understand cannabis can interact with some of them. *

I understand pregnancy and breastfeeding can affect whether certification is right for me, and I'll tell Dr. Ewals if either applies. *

I understand a history of psychosis can affect whether certification is right for me, and I'll tell Dr. Ewals about my mental health history. *

The law

I understand federal law differs from state law. A North Dakota or Minnesota card is issued under that state's law only. *

I understand Alternative Health MD can't tell me a card is valid anywhere else, and I'll check the laws of any place before I travel. *

I'll follow my state's program rules, including buying only from the places my state allows. *

I know I can ask Dr. Ewals about any of these risks at my visit. *

Signature

Signature *

Typing your full legal name here is your electronic signature.

Today's date *

If you are signing for the patient, your relationship to them

For example, parent, legal guardian or personal representative.

Sent privately to our care team