What types of treatment have you taken for your medical condition in the past?
PATIENT ATTESTATION. I attest that I am a Florida resident and the information on this form is correct. Any and all medical history, presented or omitted, is factual and complete to the best of my knowledge. I do not plan or intend to use my physician’s recommendation for purposes of illegally obtaining, growing, or distributing medical marijuana. I am aware that the KindHealth doctor will revoke my recommendation and legal actions will be taken if it is found at any time that I have perjured or misrepresented myself or my condition, intentions, or falsiﬁed any medical records to the physician. I have read and understood this attestation. DO NOT SUBMIT THIS FORM IF YOU DO NOT UNDERSTAND AND AGREE WITH THIS ATTESTATION.
RELEASE of LIABILITY I attest that I am a Florida resident and the information on this form is correct and any medical history presented or discussed with the doctor is all factual and complete to the best of my knowledge. I do not plan or intend to use my physician’s recommendation for purposes of illegally obtaining, growing, or distributing medical marijuana. I am aware that the KindHealth doctor will revoke my recommendation and legal actions will be taken if it is found at any time that I have perjured or misrepresented myself or my condition, intentions, or falsified any medical records to the physician. Solely for verification purposes, I authorize the KindHealth staff/contracted doctors to converse regarding my medical condition.
I understand the United States Food and Drug Administration does not regulate cannabis and it may therefore contain unknown quantities of active ingredients, impurities and/or contaminants. I understand the potential risks associated with an elevated daily consumption of medical marijuana including risks with respect to the effect on my cardiovascular, pulmonary systems and psychomotor performance. There are also risks associated with the long-term use of marijuana as well as potential drug dependency. I am aware the benefits and risks of using marijuana are not fully understood and may involve risks not yet identified. In requesting an approval or recommendation for the use of medical marijuana, I assume full responsibility for any risk involved in this action.
I understand medical marijuana smoke contains chemicals known as tars that may be harmful to my health. Research indicates that vaporizing cannabis may eliminate exposure to tar. If I experience any respiratory problems or other ill effects be experienced in association with its use, I should discontinued its use and report to the physician immediately.
I am advised the use of medical marijuana might affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my cannabis use.
Florida’s Medical Marijuana Legalization Initiative - Amendment 2, approved November 08, 2016 provides for the possession of medical marijuana for the personal medical purposes of the patient with a physician approval or recommendation. KindHealth staff, physicians and/or representatives are not providing medical marijuana, nor are they encouraging any illegal activity in my obtaining medical marijuana.
I attest that I am not a member, employee or agent of any media or law enforcement agency. It is illegal to ﬁlm or record in this ofﬁce with a video camera, cell phone or any other recording devise be it a still image, video or audio. This is a direct violation of HIPAA regulations and patient/doctor conﬁdentiality.
I, the undersigned, I affirm that I have a serious medical condition that negatively affects my quality of life. I found, or am interested in ﬁnding, whether or not medical marijuana provides substantial relief and improvement in my condition. I hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal marijuana treatment. The physician, staff, and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider.
I realize I am paying KindHealth for an evaluation to assess my eligibility for the OMMU Registry. This evaluation may find my condition as not appropriate for Florida state certification. In the case you are not found eligible, there is no refund to you as our staff has performed its medical service appropriately. In short, I am paying KindHealth for the service, not a guaranteed eligibility.
Should an approval be made for my medicinal use of marijuana, I understand there is a renewal date specified by the physician depending on the condition. I understand that it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval.
Given the potential adverse effects of smoking marijuana flower, the FL Board of Medicine requires doctors have patients use a vapor method of inhalation before advancing to flower. Purchase of a vape pen from the MMTC serves as ‘proof of vaping.’ If you then have vape pen related side effects, such as a cough, sore or harsh throat, only then can the ordering doctor add flower to your prescription. This purchase helps fulfill the requirement for both the state and doctor.
I have been shown a copy of the KindHealth Notice of Privacy Practices for my review. By signing this form, I am consenting to KindHealth’s use and disclosure of my PHI in accordance with those terms. Furthermore, the undersigned, or anyone acting on my behalf, agree to hold the physician and his/her principals, agents, and employees, free of and harmless from any liability resulting from the use of medical marijuana.
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SMS TERMS of SERVICE
KindHealth uses SMS/text messaging to send patients upcoming visit reminders. By opting-in to our SMS subscription tool, you agree to receive recurring text reminders for your scheduled visits. You may opt-out at any time by replying "UNSUBSCRIBE" to the text field.
While we do not charge for this service, you may be responsible for charges and fees associated with text messaging imposed by your wireless provider. To the extent permitted by applicable law, you agree that we will not be liable for failed, delayed, or misdirected delivery of any information sent through the service, any errors in such information, and/or any action you may or may not take in reliance on the information or Service. If help is needed, type "HELP" into the text field, or call us at (786) 953-6838 and one of our team members will assist you as soon as possible.
Your right to privacy is important to us. Your SMS number remains protected health information and we do not share it with any third party entities. We use this information solely to send you text notifications for your scheduled upcoming doctor visit, or to relay follow-up information regarding a prior visit. We do not use texting for marketing purposes. Our website does not use tracking cookies.