RENEWAL FORM

Paradise Clinic

702 255-MARA

RENEWAL Patient History

Date________________ Expiration Date of current Card ________________

Name ________________________________________________

Age___ Date of Birth __/__/___ Social Security # ___ __ ____ Driver's Lic #_______________________ (or Nevada ID #)

Address: ________________________________________________________________________________

City_________________ State __Zip ___ Marital Status: Married__ Divorced__ Single__ Separated__

Home phone:________________________ Work phone: _________________________

Cell phone:__________________________

Email: __________________________________________

Job:_________________________ Employer: ___________________________________________

Are you on Disability__ Medicare__Medicaid__ Veteran__How did you hear about us? patient referral__ news__Doctor referral__ Other________________

I, herein, disclose that I am not directly or indirectly associated with any local, state or federal law enforcement agency. Initials ________

1. Please indicate if you have been diagnosed with any medical problems including diseases of the liver, kidneys, intestinal tract, nervous system, and etc. _______________________________________________________________________

_______________________________________________________________________

Heart Disease? Explain________________________________________________________________

2. ALLERGIES: _________________________________________________________________________________________________

3. Please describe all surgeries you have had since last visit. Please list the dates, the reason, , the doctor or doctors who performed the surgery and the hospital where the surgery was performed.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Chief Complaint(s):

Describe all of your medical problems for which you seek evaluation and treatment today or the reason you use or would like to use medical marijuana.

5. List all current prescription medicines and how often you take them:

______________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________

6. Name, address, and DATE last seen by physicians (chiropractor, acupuncturist, etc) who takes care of you for your present problems:

Are you on probation or parole? θ Yes θ No If yes, is it drug-related? θ Yes θ No

8. Do you have a pending cannabis case? θ Yes θ No

Have you eve been accused or arrested for drug sales or distribution of drugs or marijuana? θ Yes θ No

Paradise Clinic

702 255-6272

RENEWAL Patient History

Date________________ Expiration Date of current Card __________

Name ________________________________________________

Age___ Date of Birth __/__/___ Social Security # ___ __ ____ Driver's Lic #_______________________ (or Nevada ID #)

Address: ________________________________________________________________________________

City_________________ State __Zip ___ Marital Status: Married__ Divorced__ Single__ Separated__

Home phone:________________________ Work phone: _________________________

Cell phone:__________________________

Email: __________________________________________

Job:_________________________ Employer: ___________________________________________

Are you on Disability__ Medicare__Medicaid__ Veteran__How did you hear about us? patient referral__ news__Doctor referral__ Other________________

I, herein, disclose that I am not directly or indirectly associated with any local, state or federal law enforcement agency. Initials ________

_______________________________________________________________________

Heart Disease? Explain________________________________________________________________

2. ALLERGIES: _________________________________________________________________________________________________

3. Please describe all surgeries you have had since last visit. Please list the dates, the reason, , the doctor or doctors who performed the surgery and the hospital where the surgery was performed.

4. Chief Complaint(s):

Describe all of your medical problems for which you seek evaluation and treatment today or the reason you use or would like to use medical marijuana.

5. List all current prescription medicines and how often you take them:

______________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________

6. Name, address, and DATE last seen by physicians (chiropractor, acupuncturist, etc) who takes care of you for your present problems:

Are you on probation or parole? θ Yes θ No If yes, is it drug-related? θ Yes θ No

8. Do you have a pending cannabis case? θ Yes θ No

Have you eve been accused or arrested for drug sales or distribution of drugs or marijuana? θ Yes θ No

Are you being investigated at work for possible drug use? _________

Have you been stopped by Authorities for possession? _________________________________________________________

9. Who did you medical marijuana recommendation or referral in the past? ________________________________________

10. Have you ever been prescribed Marinol (Dronabinol)? When _________ Physician's Name, Address and Phone: _______________________________________________________________________________________________________________________________________________________________________________________________________________

11. List how you take your medical marijuana medication:

Smoke______ Number joints per day __________

Combo Smoke and pipe ___ Number joints per day _____ Amount in pipe_______ Pipe smoking per day _______

Edibles ______ Amount consumed per day _________ How often? _______

Vaporizer _____ Amount consumed per day ________ How often?

other________

Do you take prescription medicine for your chronic problem ___ Need less?____ How has it changed, if at all?

________________________________________________________________________________________________

12. Emergency Phone number of family member, close friend or neighbor:

Name______________________________________________________________

Address____________________________________________________________

Phone #_____________________________________________________________

Patient Signature ___________________________________Date ___/__/____

Print_____________________________________________

YOUR PRIVACY IS IMPORTANT TO US.

Please indicate if you would like our calls to be discreet and private when leaving a message Yes___ No Need___

Because your entire process of obtaining permission to use medical marijuana is in our hands and the Nevada Department of Health, you may be assured the utmost in Confidentiality. We care.

The Doctor promotes the safe and responsible use of medical marijuana. Please do not drive, use heavy machinery or work while impaired or risk the health or safety of others. You may require an adjustment period as with any mind/body altering medication in order to perform certain tasks. Proceed slowly and with caution if you are a first time user of medical cannabis.

You will build up a tolerance to medicinal marijuana with continued use. In order to be a responsible user of "prescription" medical marijuana you should familiarize yourself with the Nevada Medical Marijuana Program and Federal laws regarding marijuana.

THE LAW:

Admission into the Nevada Medical Marijuana Program doesn't diminish your responsibility to follow public health and safety laws: You may never drive, sail or fly under the influence of medical marijuana; you may never possess a firearm in public under the influence of medical marijuana; and you may not even go on an amusement park ride if you're under the influence of medical marijuana. (NRS 484.379, 488.400, NRS 493.130, NRS 202.257, NRS 455B.080)

I have read the possible side effects of using marijuana as medicine as presented by the doctor.

Initial Here _______

*****************************

Physician Review: _______________________ Date:___________

RELEASE OF LIABILITYParadise Clinic702 255-MARA (6272)

I ___________________________________________________am applying for the right to use medical marijuana for the use specifically discussed with the Physician. I attest that I have been informed of the risks and discussed the risks of using medical marijuana with the Medical Practitioner.

I hereby release the Doctor, associates and Medical practice from professional or personal liability in connection with my using medical Marijuana or obtaining a Medical Marijuana Identification Card. I am aware that I must adhere to the statutes of Nevada and that Federal law prohibits the use marijuana which may result in severe penalties for use, cultivation, distribution or possession.

and that it is my responsibility to get a State ID card. I understand that my records are HIPPA protected and my information will not be shared unless required by Law. I agree to allow telephone, fax or mail verification of my participation.

I agree to not duplicate, share or alter my Physician’s Statement. If lost, I must obtain a new letter from the Doctor to license my legal use of cannabis in the state of Nevada. I further agree to carry my Nevada State Marijuana Card.

I will continue treatment with my personal Physicians and take my prescription medications as directed & monitor dose changes. I have been informed I may need less Pain, Blood Pressure and Diabetes Medicines.

I have been informed of side effects of marijuana and not to use while pregnant or nursing. I will follow up with this office. I permit all forms of communication including automated phone messages/Telemedicine/email. If requested, I may have a copy of this document.

Signature_____________________________________ Print ____________________________Date_____

POSSIBLE SIDE EFFECTS OF MEDICAL MARIJUANAParadise Clinic (702) 255-MARA (6272)

“MEDICAL MARIJUANA” (MEDICINAL CANNABIS, CANNABIS, TETRAHYDROCANNABINOLS)

CONTRAINDICATIONS:

Hypersensitivity to tetrahydrocannabinol or dronabinol products hypersensitivity to sesame oil

PRECAUTIONS:

Cardiac disorders such as arrhythmias, cardiac ischemia (usually manifest as either angina or a heart attack), concomitant use of sedatives or other psychoactive drugs, elderly patients may be more sensitive to psychoactive effects, history of substance abuse, history of psychiatric illness.

Do not drive, operate machinery, or engage in hazardous activities. Do not use during pregnancy or lactation. COMMON ADVERSE EFFECTS:

Abnormal thinking, impaired perception, impaired judgment, loss of motivation, diminished short-term memory, loss of concentration, depersonalization, euphoria, anxiety, panic attacks, paranoia, confusion, hallucinations, depression, dizziness/vertigo, drowsiness, diminished inhibitions; impaired coordination, increased risk of accidents, dry mouth, nausea, vomiting, high or low blood pressure, irregular heartbeat, increased heart rate, and “red” flushing of skin

DRUG INTERACTIONS:

Ritonavir

PREGNANCY: CATEGORY C

Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Most prescription medications are classified in Category C.

BREAST FEEDING:

Potential risk; change in therapy or care plan may be advisable

AGE RESTRICTION:

Patients age 18 and older may qualify for the use of medical marijuana, however, this office will recommend only to patients 21 and older (extraordinary exceptions may apply with written parental consent.)

The Doctor has provided and/or discussed the side effects of Medical Marijuana, and has offered a

more comprehensive copy of the side effects of the medicinal use of cannabis.

______________________________________ NAME (Print)

_______________________________ _______ PATIENT SIGNATUREDATE________________

HIPPA

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES at the Paradise Clinic and Methods of Communication Between You (patient) and Paradise Clinic and staff.

In general, the HIPAA privacy rule gives individuals the right to request on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative mean as sending correspondence to the individuals office instead of the individuals home. The Privacy Rule generally requires health care providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an author requested by the individual in person. I hereby acknowledge that I have read the Notice of Privacy Practices ('Notice') was given to me upon arrival at the Paradise Clinic.

For matters such as appointment reminders and other Protected Health Information, I wish to be contacted in the following ways (CHECK ALL THAT APPLY):

HOME TELEPHONE __IT IS OK TO CALL MY HOME PHONE. CELL TELEPHONE __ IT IS OK TO CALL MY CELL PHONE. WORK TELEPHONE __IT IS OK TO CALL MY WORK PHONE MAIL (USPS) ___Okay to send mail to my home addressPrint Name ______________________________________ Date_________________

X______________________________________ Signature

Note: if patient is a minor, parents/legal guardian must read and sign above