Please read this page in its entirety, and click the check box in the patient check-form if you have read, understood, and agree to all its statements.
- Neither the Steady Care Medical – Online Medical Card physician nor his associates are addressing specific aspects of the patient’s medical care and, unless otherwise stated, are in no way establishing ourselves as the primary care physician.
- I agree to notify the staff physician if I begin to experience respiratory problems or any other ill effects and discontinue the use of medication until further notice.
- Neither the Steady Care Medical – Online Medical Card physician nor his associates advises or condones that I discontinue treatment or medication that I take currently.
- I give my consent to have my name, date of visit and only required information to be released for the legal verification of my recommendation as needed by Law Enforcement and/or the Dispensaries.
Proposition 215 Medical Agreements:
CONTRADICTIONS, SIDE EFFECTS AND LIABILITY RELEASE
Medication allowed under Proposition 215 may affect or impair; my coordination and cognition, my ability to drive, operate heavy machinery or ability to engage in potentially hazardous activities. Vaporizers may substantially reduce many of the potentially harmful smoke toxins that are normally present in smoke, because although smoking medication under proposition 215 has not been linked to lung cancer, smoking it can cause respiratory harm such as bronchitis. Many researchers agree that such smoke contains known carcinogens (Chemicals that can cause cancer), and that smoking such medication may increase the risk of respiratory diseases and cancers of the lungs, mouth, and tongue. Such smoke contains chemicals known as tars that may be harmful to my health. I understand that side effects, while rare, may occur while I am taking such medication. These side effects have been explained to me. Side effects of medication under proposition 215 can include, but are not limited to: Anxiety, Inability to concentrate, Difficulty in completing complex tasks, Sedation, Alterations in the perception of time and space, Impairment of motor skills, reaction time and physical coordination, Low blood pressure, Dizziness, Increased talkativeness, Impairment of short-term memory, Confusion, Euphoria, Tachycardia (fast heart beat), and heart palpitations, Paranoia, Suppression of the body’s immune system, Psychotic symptoms (i.e. delusions, hallucinations) The potency and effects of medication varies. Estimating the proper dosage is very important. Symptoms of withdrawal, while generally mild, can include: Nausea, Vomiting, Disturbances to heart rhythms and numbness in the limbs, Hacking cough For some patients, chronic use can lead to laryngitis, bronchitis, and general apathy. I understand that some patients can become dependent on such medication and could experience withdrawal symptoms when they stop. Symptoms of withdrawal, while generally mild, can include:
- Feelings of depression, sadness or irritability
- Sleep disturbances
- Unusual tiredness
- Trouble concentrating
- Loss of appetite
I understand that the medical plant covered under proposition 215 is not a food crop and therefore not regulated by the Food and Drug Administration and may contain unknown quantities of impurities, active ingredients and/or contaminants. While under the influence of such medication, the use of alcohol is not recommended. The possibility exists that such medication may exacerbate schizophrenia in persons predisposed to that disorder, although such medication does not produce any known psychosis. In addition, the undersigned, my heirs, assigns or anyone acting on my behalf, hold the physician and his principals, agents and lease managers, free and harmless from any and all responsibility for any and all unforeseen harm resulting to me and/or any other individuals as a result of my use of my compassionate use recommendation. The SCMC staff physician has explained to the patient, the nature and purpose of alternative herbal medication allowed under Proposition 215 SB 420 treatment including its benefits and possible side effects and have asked the patient if he/she has any questions regarding his/her treatment with such medication and answered those questions to the best of our ability.
I certify that I have read this document and declare under penalty of perjury that the information contained herein is correct, true, and complete.