* I am requesting Junella Chin, D.O. / Jose Camacho D.O. (the “Physician”) to certify me /my child/ my legal ward as a qualifying patient under the New York Medical Marijuana Act and to treat Patient’s debilitating medical
condition as Patient uses marijuana for medical purposes. In requesting the Physician to continue treating
Patient as Patient uses marijuana for medical purposes, I assume full responsibility for any and all risks of this
action related to Patient's current medical condition.

* I understand that marijuana is not approved by the Federal Food and Drug Administration for medicinal
purposes and may contain unknown quantities of active ingredients and may potentially contain contaminants
and/or impurities. I understand that the Physician may not be knowledgeable of all the associated risks involved
in the use of a non-FDA approved substance such as marijuana. I acknowledge that there is controversy in the
medical/scientific literature available regarding the usage of marijuana for medical purposes and that more
research is currently being conducted.

*I understand that although the New York/Connecticut law has approved the limited use of marijuana for medical purposes, its use is not approved under federal law, and that the current and future enforcement action of federal law enforcement officials is uncertain.

*The Prescription will be cancelled if I don’t show up for appointments and avoid calls.

*I have had, or will have, the opportunity to discuss these matters with the physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge that the physician has not provided a recommended treatment of my condition with medical marijuana. The physician did inform me of the risks, complications of any recommended treatment I choose to do on my own after obtaining the certificate. I acknowledge the physician has, informed me of any alternatives to medical marijuana that I may pursue with my primary care provider.

*I understand that the consultation and follow up fees are non-refundable.