1. MMS shall pre-screen Member Applications. Upon completion of the MMS Application Package, MMS will perform a preliminary assessment. Your Application will not be processed if MMS feels that you have no chance of being approved for Medical Marijuana, and you will not be charged for services;

2. MMS shall arrange a confidential interview by electronic means between the Member and a highly qualified member of the medical profession authorized to approve the use of medical marijuana;

3. MMS provides advice on an ongoing basis regarding the best licensed producers and most appropriate strains of medical marijuana for the Member's condition;

4. Members receive 24 hour/7 days a week emergency assistance if police or other authorities require verification of the Medical Document;

5. All medical information shall be kept in strictest confidence. MMS will never sell or allow access to the Membership roster except on orders of the police with a court-issued warrant;

Member Obligations

6. By signing this application, MMS Members undertake to be honest and forthright regarding their medical condition when preparing the Patient Assessment Form and during the medical assessment, and to openly disclose all other prescription and non-prescription medications to the physician;

7. By signing this application MMS Members acknowledge that violation of the physician-patient contract shall immediately terminate this contract;

8. By signing this application MMS Members acknowledge that they are solely responsible for any violation of the Criminal Code or the Controlled Drugs and Substances Act;

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 Spectrum Therapeutics (ST) 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, ST, 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, ST 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 ST's use and sharing my anonymous data with research organizations and for commercial purposes. I acknowledge and understand that MMS and ST 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 ST.

I hereby acknowledge and understand that MMS and ST 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 ST 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.

PATIENT ACKNOWLEDGMENT AND AGREEMENT:

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communication Services more fully described in the Appendix to this consent form. I understand and accept the risks outlined in the Appendix to this consent form, associated with the use of the Services in communications with the Health Care Practitioner (HCP), Medical Marijuana Services (MMS) and Spectrum Therapeutics (ST) and the HCP, MMS’s and ST's staff. I consent to the conditions and will follow the instructions outlined in the Appendix, as well as any other conditions that the HCP, MMS and ST may impose on communications with patients using the Services.

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the HCP, MMS and ST or the HCP, MMS’s staff and ST's staff using the Services may not be encrypted.

Despite this, I agree to communicate with the HCP, MMS and ST or the HCP, MMS’s staff and ST's staff using these Services with a full understanding of the risk.

I acknowledge that either I or the HCP, MMS and ST may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice. Any questions I had have been answered.

RISKS OF USING ELECTRONIC COMMUNICATION

The HCP, MMS and ST will use reasonable means to protect the security and confidentiality of information sent and received using the Services (“Services” is defined in the attached Consent to use electronic communications). However, because of the risks outlined below, the HCP, MMS and ST cannot guarantee the security and confidentiality of electronic communications:

• Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
• Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.
• Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
• Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.
• Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the HCP, MMS and ST or the patient.
• Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
• Electronic communications may be disclosed in accordance with a duty to report or a court order.

Videoconferencing using services such as Medeo, Skype, OTN may be more open to interception than other forms of videoconferencing. If the email or text is used as an e-communication tool, the following are additional risks:

• Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
• Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent. Conditions of using the Services
• While the HCP, MMS and ST will attempt to review and respond in a timely fashion to your electronic communication, the HCP, MMS and ST cannot guarantee that all electronic communications will be reviewed and responded to within any specific period of time. The Services will not be used for medical emergencies or other time-sensitive matters.
• If your electronic communication requires or invites a response from the HCP, MMS and ST and you have not received a response within a reasonable time period, it is your responsibility to follow up to determine whether the intended recipient received the electronic communication and when the recipient will respond.
• Electronic communication is not an appropriate substitute for in-person or over-the-telephone communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed. You are responsible for following up on the HCP, MMS and ST’s electronic communication and for scheduling appointments where warranted.
• Electronic communications concerning diagnosis or treatment may be printed or transcribed in full and made part of your medical record. Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications.
• The HCP, MMS and ST may forward electronic communications to staff and those involved in the delivery and administration of your care. The HCP, MMS and ST might use one or more of the Services to communicate with those involved in your care. The HCP, MMS and ST will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.
• You agree to inform the HCP, MMS and ST of any types of information you do not want sent via the Services, in addition to those set you can add to or modify the above list at any time by notifying the HCP, MMS and ST in writing.
• Some Services might not be used for therapeutic purposes or to communicate clinical information. Where applicable, the use of these Services will be limited to education, information, and administrative purposes.
• The HCP, MMS and ST are not responsible for information loss due to technical failures associated with your software or internet service provider.