Please read and sign the form below. Once you click submit, you will automatically be taken to the final step for patient registration. RELEASE OF LIABILITY Name* Mr.Mrs.MissMs.Dr.Prof.Rev.Prefix First Middle Last Suffix Email Section 1 Initials* 0 of 5 max characters I, for myself, my heirs, assign, or anyone acting on my behalf, hold Green Palms Health and Wellness, LLC, and its principals, agents, and employees free of and harmless from any responsibility for any harm resulting to me and/or other individuals because of my Low TCH or Medical Marijuana use. Section 2 Initials* 0 of 5 max characters I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and therefore may contain unknown quantities of active ingredients, impurities and/or contaminants. In requesting an approval or recommendation for use this plant as medication I assume full responsibility for any and all risk or this action. Section 3 Initials* 0 of 5 max characters I’m advised that the use of cannabis may affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and /or other individuals as a result of my use of cannabis. Section 4 Initials* 0 of 5 max characters I certify that I fully understand the potential risks and side effects related to the use of Medical Marijuana as described above. Section 5 Initials* 0 of 5 max characters In using Medical Marijuana, I fully accept responsibility and assume the risks and side effects associated with its use. Section 6 Initials* 0 of 5 max characters I agree that Green Palms Health and Wellness,LLC and its employees shall not be held responsible for any harm resulting to me and/or any other individual(s) because of my use of Medical Marijuana. Section 7 Initials* 0 of 5 max characters I certify that I have read this document and declare under penalties of perjury that the information contained herein is true, correct, and complete. Physician’s Name being Released* I release the named Physician above from any and all actions, causes of actions, claims, complaints and demands for damages, loss or injury whatsoever arising directly or indirectly as a consequence of my application with my use of marijuana. This release from liability is to be binding on my Heirs, Executors and Assigns. Select a Date* Digital Signature* By typing your full legal name, this serves as your legal signature and that you acknowledge you have read and agree with or will comply with the terms of the document you are signing under penalty of perjury.