Please complete client information below, read the informed consent agreement, and sign at the bottom before submitting. Alternatively, the PDF form version is available to print and can be found on the Services & Fees page on our website. Feel free to contact us with questions.
Name
DOB
Address
Phone Number
Email
What is your preferred method of communication?
Are you a registered medical cannabis patient in Virginia or other state?
Who provided your written recommendation for medical cannabis?
For what condition/ailment are you seeking to benefit from medical cannabis?
Current medications (including vitamins, supplements, herbals, etc)?
Do you have any Allergies? If YES, please describe below.
Do you have a caregiver or other support at home, i.e., spouse/partner/family? Please describe.
Occupation?
What is your experience with cannabis? Past/present use? Please describe.
Have you experienced any undesirable effects from cannabis? Please describe.
What is your preferred method of cannabis consumption;
Do you have any other health conditions, i.e., asthma, COPD, liver/renal disease, high blood pressure, cardiac, or psychiatric conditions, etc.? Please describe below.
Do you use (past or present) any illicit drugs or non-prescription medications other than cannabis? If yes, please describe.
Do you have a location to properly and securely store your cannabis medicine and keep it safely away from others, especially those under the age of 21?
MEDICAL ADVICE DISCLAIMER: The information, including but not limited to, text, graphics, images and other material contained in this website and through the services provided by Sarah O’Hanlon of CannEducate Virginia, LLC are for informational purposes only. No material shared with our clients is intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment, and before undertaking a new health care regimen. Do not disregard professional medical advice or delay in seeking it because of something you have read or heard through any other resources.
By law, Sarah O’Hanlon of CannEducate Virginia, LLC is not permitted to diagnose, treat, or prescribe medications. It is recommended that you seek professional medical guidance regarding any illness or symptoms you are experiencing, and to inform your physician or healthcare provider of any and all supplements you are taking. Furthermore, the client is advised not to make any adjustments to any prescribed medication for any condition without the approval of a doctor or healthcare provider. The client is also advised to seek a physician's or healthcare provider’s advice for any/all healthcare related services.
By entering into this agreement, the client agrees to the following:
Except in the case of gross negligence or malpractice, I agree to fully release and hold harmless Sarah O’Hanlon and CannEducate Virginia, LLC, and any staff members from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with provided services.
That under no circumstances, including but not limited to negligence, shall Sarah O’Hanlon and CannEducate Virginia, LLC be liable for any special or consequential damages in any way whatsoever, now or in the future, that results from the use of or the inability to apply services, and, that the information, protocols, methods, references or recommendations by CannEducate Virginia, LLC are not intended to substitute for the diagnosis and care of a qualified physician or healthcare provider, nor to encourage the treatment of illness by persons not appropriately trained and legally qualified.
Sarah O’Hanlon and CannEducate Virginia, LLC reserves the right to terminate services for any reason, including but not limited to, noncompliance, withholding pertinent information, and any other high-risk behaviors.
By electronically signing below, I am confirming that all information is true to the best of my knowledge, and I agree to all the terms and conditions listed above. I am also acknowledging that Sarah O’Hanlon of CannEducate Virginia, LLC makes no claims to be a healthcare provider to diagnose or treat illness, or to prescribe medications.
Signature
Printed Name
Date Signed
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