First-time Patient Release (Form 2 of 3)

Please review this form carefully before signing. 

1. The patient must discuss the use of medical marijuana with his or her treating health care practitioner. The patient should inform his or her treating health care practitioner(s) about the use and dosage of medical marijuana the patient receives from Vireo Health of New York and any other medical marijuana provider.

2. The patient should continue to receive and comply with regularly scheduled treatment for his or her qualifying medical condition(s) from the patient’s health care practitioner(s) and report any changes in the patient’s medical condition to his or her health care practitioner(s).

3. Medical marijuana medications have not been approved by the FDA. Vireo Health of New York provides no representations or guarantees as to the effectiveness of its products or the products’ ability to treat or benefit any medical conditions. There is limited information on the side effects of medical marijuana products and some of the existing information suggests that medial marijuana use can be harmful. The patient is taking Vireo Health of New York’s products at his or her own risk.

4. Medical marijuana may affect your coordination and cognition in ways that impair your ability to perform various activities including, but not limited to, your ability to drive or operate a vehicle or machinery and you must agree not to drive or operate any vehicle or machinery or engage in any potentially dangerous or hazardous activities when using or impacted by medical marijuana. The patient should use great care in all activities until he or she becomes familiar with the products’ effects.

5. Side effects may occur while you’re taking or after taking medical marijuana. Side effects may include, but are not limited to, increased heart rate, euphoria, dysphoria, confusion, low blood pressure, dizziness, inability to concentrate, sedation, anxiety, paranoia, delusion, suppression of the body’s immune system, impairment of memory, alterations of perception of time and space, difficulty in completing tasks, impairment of motor skills, reaction time and physical coordination.

6. Some patients may become dependent on medical marijuana and they may experience withdrawal symptoms when they attempt to stop using medical marijuana.

7. A person who sells or transfers medical marijuana products to persons other than the registered patient for which the products are intended for can be found guilty of various criminal charges including criminal diversion in the second degree. Vireo Health of New York may have an obligation to assist in the prosecution of any diversion of medical marijuana products if it becomes aware of such diversion.

8. There are a number of restrictions on where medical marijuana can be used and in what form. Information regarding these restrictions can be found on the New York State Medical Marijuana Program website.

This form is not comprehensive of medical marijuana information and does not include all information that may be relevant to a patient or caregiver. If you have any questions regarding your medical marijuana treatment or the New York medical marijuana program, please call us: (844) 4-VIREONY.

I represent that I have thoroughly reviewed the above information and have been informed of the risks associated with the use of medical marijuana. I am also aware and understand that medial marijuana cannot be legally consumed under federal law and various state and local laws. I have discussed my use of medical marijuana with my health care practitioner(s). To the fullest extent permitted by applicable law, I agree to release and not bring claim against Vireo Health of New York, LLC or any of its affiliates or their respective employees, agents, members, managers, officers, successors or assigns in connection with their cultivation, acquisition, manufacture, possession, preparation, transfer, transport, storage, supply or dispense of medical marijuana to me or in my purchase of related devices or supplies.