House of Jane - New Patient Agreement (online format)

House of Jane - New Patient Agreement (online format)

medical marijuana dispensary/patient sign-up Form Preview
House of Jane - New Patient Agreement (online format)
  • HOUSE OF JANE

  • New Patient Intake Form

    All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.

  •  -  - Pick a Date
  •  -  - Pick a Date
  • AGREEMENT

  • By signing this agreement you are joining as a member of House of Jane, a California Not for Profit Organization. As a member you may
    participate as a non-voting member in the collective and the services it provides. You agree that you are responsible for following guidelines. 
    If you do not follow these guidelines your membership will be terminated and we will refuse you service. 
    - You agree not to divert marijuana for non-medical purposes under any circumstances.
    - You agree to follow all rules of conduct established by the collective. 
    House of Jane reserves the right to refuse service and or membership to anyone, at any time, at their discretion, and may terminate 
    membership at their discretion
    You agree to allow House of Jane to grow and process medical marijuana on your behalf and to provide you services as your 
    caregiver in your health related and personal needs.
    As a condition of using our services and/or by utilizing such medicine/herbal marijuana and related products as you may obtain, you, 
    your heirs and those with you, expressly and forever release House of Jane, its owners, landlord, operators, managers, employees, 
    agents, attorneys, growers, providers, wholesalers, officers, directors, members, from and against any and all lawsuits, alter-ego 
    lawsuits, demands, charges or claims with reference to the strength, potency, purity, toxicity, appropriateness for your condition of 
    any marijuana and related products you may obtain from House of Jane.
    As a condition of using our services and/or by utilizing such medicine/herbal marijuana and related products as you may obtain, you, 
    your heirs and those with you expressly and forever waive any and all claims now known, or discovered at any time in the future due 
    to, related to or arising from your storage or handling of marijuana or any other product/herb/food/oil/concentrate you may obtain 
    form us. 
    KEEP ALL MEDICINE FAR, FAR AWAY FROM CHILDREN OR ANYONE ELSE, AND UNDER LOCK AND KEY. ANY 
    DEVIATION FROM THIS RULE IS DONE AT THE SOLE RISJ AND RESPONSIBILITY OF THE PATIENT.
    You agree, as a patient member of House of Jane, to abide by these rules and regulations.

  • 1. I have been diagnosed with a serious illness for which cannabis provides relief and I have received a recommendation 
    2. I understand my contributions for medicines I may require from this collective are used to ensure continued operation 
    3. The monies I donate are to help the collective continue to operate, to maintain employees and a location and the 
    4. The collective may cultivate, obtain, transport and possess cannabis on my behalf.
    5. I designate the collective as my caregiver for medical marijuana.
    6. I authorize the collective to contact my physician, and I authorize my physician to verify my recommendation to the 
    7. I agree that I consistently rely upon the collective as the exclusive source of my cannabis medicine (except such 
    8. The designation shall remain in effect for 12 months, until the expiration of my recommendation, or until I revoke my 
    or approval from my licensed California physician to use cannabis.
    and that this transaction in no way constitutes commercial promotion.
    associated costs and expenses of providing its members with medicinal marijuana for their medical needs.
    collective.
    medicine as I may cultivate individually).
    designation in writing by certified mail, return receipt requested, whichever comes first.

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