I agree that the following statements are true and accurate:
I am over 18 years of age and I am registered with and understand the requirements of the State of Connecticut’s medical marijuana program.
I agree to strictly comply with the regulations, terms and conditions of the State of Connecticut’s medical marijuana program. No cannabis obtained by me shall be used for any other purpose than as directed by my certifying physician. I understand cannabis is not to be resold, distributed, or used by any other person.
I fully accept the responsibility in using cannabis and I certify I fully understand the potential risks related to the use of cannabis products.
If I start using cannabis, I agree to tell my physician if I experience any one or more of the following:
- Start to feel sad or have crying spells
- Have changes in my normal sleep patterns
- Lose my appetite
- Become more irritable than usual
- Become unusually tired
- Withdraw from my family and friends
- Lose interest in your usual activities
In the event that I experience a severe adverse reaction, I am advised to immediately contact my physician. In the event that my physician is not available, I agree to call 911 for help, lie down and relax until help arrives.
I agree to tell my physician if I have ever had symptoms of schizophrenia, bipolar disorder,psychotic episodes or attempted suicide. I also agree to tell my medical professional if I have ever been prescribed or taken medicine for any of these problems. I acknowledge that the risks of using cannabis under these circumstances could be severe.
I understand that my physician does not suggest nor condone that I cease treatment of medications that stabilize my mental or physical condition.
I am not pregnant, intending to become pregnant, or breastfeeding.
I certify that I have read this document and declare that the information contained herein is true, correct and complete.