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First Name* Last Name* Date of Birth *(mm/dd/yyyy) Mobile Phone* Email Address This will be your username. Dont forget it!* If you have other family members sharing the same email address, you all must register with unique email addresses.

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Address Current Physical Address* City* State* Zip* Gender*

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Q1: What is/are the main medical problem(s) which you currently have or have had in the past ?( Select an HIV/AIDS, Arthritis, Chronic Pain, Loss of Appetite, nausea, Muscle Spasm, Glaucoma, Weight Loss, Fibromyalgia, Migraine Headaches, Cancer, Seizures, Trouble Sleeping, Anxiety, or Other): Q2: Do you currently use specific medications for your medical condition? Q3: Are you taking any prescription medications or herbs? Q4: Do you have any allergies to any medications? Q5: Have you ever had any surgeries or been hospitalized? Q6: Do you exercise?

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Q7: Do you smoke tobacco? Q8: Do you drink alcohol? Q9: Are there health/medical problems that occur frequently in your family? Q10: Have you experienced or been diagnosed with any of the following: Depression, Bipolar Disorder, Schizophrenia, Suicidal thoughts, ADHD? Q11: Do you have a primary care provider? Q13: When was the last time you saw your doctor/ specialist about these complaints? List all medications you're sensitive to: Who referred you to Hamptons Medi Spa?

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Please read the Release of Liability and scroll down to check the box below.

Informed Consent and Release of Liability Form
                    
Please read each item below and check the box provided at the end of this form to indicate you understand the information
regarding the risks and side effects of using marijuana. I agree to tell the attending physician if I do not
understand any of the information provided.

Under federal and state law, it is not permitted to use or possess marijuana within 1000 feet of a daycare or
school. I agree not to do so.

I agree not to use marijuana while under the influence of alcohol.

I understand that it is against the law to drive a vehicle while using marijuana and that doing so will result in a
DUI for driving under the influence

I agree to tell the attending physician if I have ever had symptoms of depression, been psychotic, attempted
suicide or had any other mental problems. I also agree to tell the attending physician if I have ever been
prescribed or taken medicine for any of the conditions stated above. Furthermore, I understand that the attending
physician does not suggest nor condone that I cease treatment and/or medication that stabilize my mental or
physical condition

I agree to immediately stop using marijuana and inform the physician in the event I become suicidal,
homicidal, paranoid or have an increase in any of these symptoms.

There are few known interactions between marijuana and medications or other herbs. However, very few
interactions between herbs and medications have been studied. I agree to tell my attending physician if I am using
any herbs, supplements or other medications.

Some users might develop a tolerance to marijuana. This means higher and higher does are required to
achieve the same clinical effect. It is recommended for doctors to have an intermission with drug for at least 3
weeks every 3-4 months. If I think I may be developing a tolerance to marijuana. I will notify my attending
physician.

Should respiratory problems or other ill effects be experienced in association with the use of medical
marijuana, I agree to discontinue its use and report any or report such problems or effects to the attending
physician. Although smoking marijuana has not been linked to lung cancer, smoking marijuana can cause
respiratory harm, such as bronchitis. Many researchers agree that marijuana smoke contains known carcinogens
(chemicals that can cause cancer), and that smoking marijuana may increase the risk of respiratory diseases and
cancers of the lungs, mouth and tongue. I have been advised that cannabis (medical marijuana) smoke contain
chemicals known as tars that may be harmful to my health. Vaporizers may substantially reduce many of the
potentially harmful smoke and toxins that are normally present in marijuana smoke.
                        
Marijuana varies in potency. The effects of marijuana can also vary with the delivery system. Estimating the
proper marijuana dosage is very important. Symptoms of marijuana overdose include, but are not limited to
nausea, vomiting, hacking cough, disturbances to heart rhythms and numbness in the limbs.
                        
The efficacy and potency of marijuana varies widely depending on the marijuana strain and ingestion method.
Under federal law, the attending physician is unable to discuss dosage.
                        
I agree to use birth control while using marijuana. In the event I become pregnant, I agree to immediately
discontinue use of marijuana and contact the physician. (Females only)
                        
Cannabis is not regulated by the USFDA and therefore may contain unknown quantities of active ingredients,
impurities and or contaminants.
                        
I intend to obtain and use medical marijuana in the State of New York for my medical condition should medical
marijuana be recommended for my condition
                       
I understand that side effects may occur while I am taking medical marijuana can include but are not limited to:
                        Short term memory loss
                        Anxiety/Nervousness
                        Irregular Heart beat
                        Dry Mouth
                        Slower reaction time
                        Poor physical coordination
                        Hunger
                        Loss of Appetite
                        Dizziness
                        Cough
                        Dependency
                        Confusion
                        Impaired Vision
                        Feeling of Euphoria
                        Tiredness Drowsiness
                        Headache
                        Nausea/Vomiting
                        Apathy
                        Change in sleeping patterns
                        Numbness
                        Laryngitis
                        Bronchitis
                        Depression
                        Agitation/Irritability
                        Trouble Concentrating
                        High or Low blood pressure
                        Sedation
                        Difficulty completing complex tasks
                        Inability to concentrate
                        Paranoia, psychotic symptoms (i.e., delusions)
                        Suppression of immune system (ft)Talkativeness
                        Impairment of motor skills, coordination, and reaction time
                       
I understand there may be benefits and risks associated with marijuana use that have not been identified.
                        
If I start taking medical marijuana, I agree to immediately tell my physician if I:
                        Start to feel sad or have crying spells
                        Lose interest in my usual activities
                        Have changes in my normal sleep patterns
                        Lose my appetite
                        Withdraw from family and friends
                        Become more irritable than usual
                        Become pregnant
                        Become unusually tired

I confirm that the information provided by me regarding my diagnosis and medical records, is true and correct. Check this box if you agree to our terms:

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Also please review this document: NYS Medical Marijuana Law - Full legal document

Photo ID Required

Please attach a photo or scan of your non-expired drivers license or other photo ID.

Make sure the image is one of the following formats: jpg, png, bmp, jpeg

When you attach the image it will be uploaded to our servers when you click 'Register'. No additional steps are required.

If you DO NOT have an image available currently or are unsure how to attach it, you can at a later date upload/email it. Our practitioners will walk you through the steps.

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Please read the Release of Liability and scroll down to check the box below.

Photo ID Required

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