Green Cross Partners
Serving Michigan Since 2009!
3737 Lake Eastbrook Blvd. SE, Ste. 114, Grand Rapids, MI 49546
Terms of Service
Last Updated: 01/01/2019.
MEDICAL MARIJUANA PATIENT DECLARATION
I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition and attest that I do not intend to use my medical recommendation for the purpose of illegally obtaining, growing or distributing 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 device be it a still image, video or audio. This is a direct violation of HIPAA regulations and patient/doctor confidentiality.
I am aware that my recommendation can be revoked at any time and legal actions will be taken if I have perjured or misrepresented myself or my condition, my intentions or falsified any medical records to the physician. I also hereby authorize Green Cross Partners or its representative, to discuss my medical condition for verification purposes only.
Additionally, I acknowledge the attending physician will or has informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana. The risks, complications and expected benefits of any recommended treatment, including its likelihood of success or failure. I acknowledge the attending physician informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and their risks and benefits. The physician may request that I visit another physician or specialist to further substantiate my condition. I will be informed of all the above-mentioned regardless of whether or not I qualify as a patient.
LIABILITY WAIVER AND RELEASE
In consideration of the medical evaluation of me to be performed by or on behalf of Green Cross Partners, I, my heirs, assigns and anyone acting on my behalf, agree to hold Green Cross Partners, and their principals, agents, officers, directors, contractors, and employees, free and harmless from any and all claims, damages and causes of action relating to or arising out of:
(1) my use or possession of cannabis (marijuana), or
(2) the denial of my application for a medicinal marijuana card for any reason.
I understand and acknowledge that:
Green Cross Partners is not a Dispensary and cannot provide me with medicinal marijuana or any other medication;
An evaluation that results in a physician's recommendation that I may benefit from the use of medicinal marijuana does not guarantee that I will in fact be eligible to obtain, possess or use medicinal marijuana pursuant to Michigan law;
A physician’s recommendation that I may benefit from the use of medicinal marijuana does not guarantee that the use of medicinal marijuana will be effective at alleviating my pain;
Neither Green Cross Partners, nor anyone acting on Green Cross Partners behalf has made any representation to me about the application or enforcement of federal law in connection with the possession or use of medicinal marijuana; and
I am signing a complete release (to the extent permitted under applicable law) of any claims arising from my medical evaluation.
In addition, I represent that Green Cross Partners' physician will or has:
(a) explained to me the nature and purpose of medical cannabis (marijuana) treatment including its benefits and possible side effects,
(b) asked me if I have any questions regarding his/her recommendation or my treatment and
(c) answered those questions, if any, to the best of his/her ability.