Last Name (required)
Date Of Birth (required)
Your Email (required)
How did you hear about us? (required)
Patient ID #
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Patient Drivers License/ID #
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Full Name (required)
Phone Number (required)
Please indicate any prescribed and/or over-the-counter medications that you are currently taking
Name & Dosage
Interactions (if known)
I certify that the above information is correct. I understand my information is protected by Federal and State Laws and will not be
disclosed to anyone outside of The Nirvana Center or the Arizona Department of Health Services without my written consent.
Medical Marijuana Acknowledgment of Disclosure and Informed Consent
Please read below and sign to indicate that you understand and agree you have been advised of the health risks of medical marijuana.
By signing, you understand and agree to the information. If you have questions or do not understand the information below, consult
with a dispensary employee before initialing or signing this agreement. Please do not sign this agreement and do not use medical
marijuana if you do not understand the following information you have received. I understand that medical marijuana is a medicine
used in treating the suffering caused by serious and debilitating medical conditions. Serious and debilitating medical conditions
include cancer, HIV, nausea, arthritis, chronic pain, glaucoma, cachexia, migraine headaches, anorexia, seizures, and persistent muscle
spasms. Additionally, medical marijuana is used in the treatment of other chronic or persistent symptoms that:
• Substantially limits the ability of the person to conduct one or more major life activities as defined in the American with
Disabilities Act of 1990 (Public Law 101-336)
• Other conditions for which marijuana provides relief;
• If not alleviated, may cause harm to the patient’s safety or physical or mental health.
• I have been advised that the use of cannabis (medical marijuana) may affect my coordination and cognition in ways that
could impair my ability to drive a vehicle and agree not to operate heavy machinery, drive or engage in potentially
• I understand the side effects may occur while I am taking medical marijuana. Side effects of medical marijuana can include
but are not limited to: increased heart rate, euphoria, dysphoria, confusion, low blood pressure, dizziness, inability to
concentrate, sedation, anxiety, paranoia, delusion, suppression of the body’s immune system, impairment of shorter term
memory, alterations in the perception of time and space, difficulty in completing complex tasks, impairment of motor skills,
reaction time and physical coordination.
• I understand that some patients can become dependent on marijuana. This means they experience mild withdrawal symptoms
when they stop using marijuana, Signs of withdrawal symptoms, while generally mild can include: feelings of depression,
sadness and irritability, restlessness or mild agitation, insomnia, loss of appetite, sleep disturbance, trouble concentrating, and
• Although marijuana does not produce specific psychosis, the possibility exists that may exacerbate schizophrenia on persons
predisposed to that disorder.
• I will not divert medical marijuana to any individual or entity that is not allowed to possess marijuana pursuant to A.R.S.
• I will not use medical marijuana in a public place meaning any location, facility, or venue that is not intended for the regular
exclusive use of an individual or a specific group of individuals.
• I am here under my own free will, I am of sound mind and have been informed of the risks associated with the use of medical
Please provide your signature stating you have been advised of the health risks associated with medical marijuana and will
not hold The Nirvana Center liable for any side effects that you may experience or any legal consequences that may arise due
to medical marijuana purchased at this dispensary.
Please sign your full name below