I hereby acknowledge and agree to the following terms of treatment:

I understand that this Release and Acknowledgement contains IMPORTANT information about medical cannabis that the assessing Health Care Practitioner (HCP) requires that I acknowledge and understand before they may issue a prescription and/or authorization for use of medical cannabis.

I further understand that the consulting HCP will not necessarily be assuming care for me. The consulting HCP will, however, assess and evaluate the appropriateness of my request to use medical cannabis to assist in treating the conditions and associated symptoms that I believe, from my own personal experience, medical cannabis to be helpful in treating.

I accordingly confirm that the assessing HCP will be my medical practitioner for the sole purpose of medical cannabis authorization and/or prescriptions.

I agree not to make any claim or commence any legal proceedings against the assessing HCP, their practice, my family HCP or any other involved HCP's (such as specialists) in relation to:

a) my use of cannabis as a medicine; and

b) my Application or prescription for possessing, obtaining and using medical cannabis.

I am well aware that HCP's generally agree that medical cannabis:

• May distort perception (sight, sounds, time, touch);
• May impair memory and learning;
• May impair coordination (Avoid driving for 4 hours after smoking and 8 hours after ingesting);
• May impair thinking and problem-solving;
• May increase heart rate and reduces blood; and
• May produces anxiety, fear, distrust, or panic;

I am well aware there is considerable debate and a great lack of consensus among HCP's about:

• The appropriate medical use of cannabis;
• The appropriate dosage for medical cannabis;
• The risks of smoking medical cannabis as compared to vaporizing or ingesting medical cannabis;
• The risks of smoking whole plant medical cannabis as compared to extracting the medicinally active cannabinoids and medicating with same;
• The long-term health and psychological risks associated with the use of medical cannabis;
• The degree to which regular consumption of medical cannabis;

a) may contribute to pulmonary infections and respiratory cancer,

b) may damage the cells in bronchial passages which protect the body against inhaledmicroorganisms and decrease the ability of the immune cells in the lungs to fight offfungi, bacteria, and tumor cells. For patients with already weakened immune systems,this means an increase in the possibility of dangerous pulmonary infections, includingpneumonia,

c) may weaken various natural immune mechanisms, including macrophages and T-cells,and

d) may correlate in some cases with mental illness, such as bipolar disorder and schizophrenia.

I am further well aware that the above listed medical concerns are further compounded by the lack of consistency and uniformity in available medical cannabis products. With conventional drug products, I generally consume a medication of a precisely known molecular quantity. I recognize that raw plant Medical Cannabis does not work this way. I appreciate that I will get varying compositions of different cannabinoids and varying proportions of different cannabinoids from strain-of-plant to strain-of-plant and even, to a lesser degree, from plant-to-plant of the same strain.

I further appreciate that there is a significant uncertainty regarding the consistency of the medical cannabis drug product I use to medicate which further complicates and compounds the practical issue of medicating with an inconsistent drug product like medical cannabis.

I am further aware that ingesting a high dose of medical cannabis can cause nausea and disorientation.

In seeking medical cannabis treatment, I acknowledge and confirm that I have consulted with a HCP regarding alternative and conventional treatment options for my condition.

Despite all these medical concerns, debates and practical issues, I honestly believe that for the treatment of my condition(s) and symptom(s) the benefits of medicating with medical cannabis outweigh the risks.

I agree to receive a “medical document” (ie prescription) for medical marijuana exclusively from one HCP. I further agree to purchase my marijuana exclusively from a licensed producer (LP). I acknowledge and understand that possession of marijuana from other sources is illegal. In the event that I decide to change LP's, I will provide Medical Marijuana Services (MMS) and Cannabis Access Centre (CAC) with written notice.

I agree to safely store my marijuana so that no other person can access it either deliberately or accidentally. I am aware that young people, particularly those under 25, may experience psychosis after consuming marijuana and will ensure that no child or young person will be exposed to my medical marijuana, either directly or indirectly. I will contact Poison Control immediately if any child gains access to my supply of medical marijuana.

I am aware that taking marijuana with other substances, especially sedating substances, may cause harm and possibly death. I will not use illegal drugs (e.g., cocaine, heroin) or controlled substances (e.g., narcotics, stimulants, anxiety pills) that were not prescribed for me.

I will inform the HCP of all controlled substances that are prescribed to me by my regular HCP(s). I will inform my primary care HCP that I am being prescribed medical marijuana. I agree to have a medical assessment performed by my regular HCP at least every 12 months.

I am aware that marijuana use is not advisable during pregnancy and breastfeeding. I agree to inform my HCP, if I am pregnant. If I become pregnant while being treated with medical marijuana, I will immediately stop using it until I have consulted with a HCP.

This is my decision and I also do not support any claims made by my family, friends or other interested parties against said clinic and HCP's.

I hereby release MMS, CAC, the assessing HCP, the assessing HCP’s clinic, my family HCP, and any other involved HCP's from any and all actions, claims, causes of actions, complaints (even by family and friends) and demands for damages, loss, or injury whatsoever arising, directly or indirectly, as a consequence to my use of medical cannabis and my Application to possess medical cannabis. This release from liability is to be binding on heirs, executors and assigns.

I hereby acknowledge and consent to the disclosure, sharing and use of my personal information and medical data by the assessing HCP, MMS, CAC and my licensed commercial producer. The personal information and personal health information collected may be used to contact, assess and register the patient and for analysis and research to better help our members.

By signing this consent, I agree and consent to MMS'and CAC's use and sharing my anonymous data with research organizations and for commercial purposes. I acknowledge and understand that MMS and CAC do not consider aggregated and anonymized information to be personal information or personal health information. I further acknowledge and understand that I will not be compensated as a result of the analysis or research performed using my data, and any discoveries resulting therefrom shall be the exclusive property of MMS and CAC.

I hereby acknowledge and understand that MMS and CAC reserve the right to transfer any personal information and personal health information collected in the event that they sell or transfer all or a portion of their business or assets to a third party. Further, I acknowledge and understand that MMS and CAC reserve the right to disclose any personal information and personal health information, as needed, if such information is requested by law enforcement agencies, or if they are requested to do so by law, regulation, court order, or by a government entity.

I hereby understand and acknowledge that while the assessing HCP may execute a declaration that I stand to potentially benefit from medical cannabis, the assessing HCP will not serve as my primary care HCP. As such, I agree to seek regular medical care from my primary care HCP and that the assessing HCP will only deal with assessing his support for my medical cannabis use. I also consent to the assessing HCP notifying any specialists of my decision to use medical cannabis and accept any consequences of such notification.

I hereby agree to notify my primary care HCP about my intent to use cannabis medicinally as cannabis can interact with other medications. I hereby agree that, if provided a prescription for medical marijuana, I shall not re-sell, assign or transfer any of my medication.

I hereby agree to check with local by-laws in my area. I also agree that any legal actions will take place in Ontario and be governed by the laws of Ontario, Canada.