I declare the following to be true:
• I am at least 19 years of age;
• I am aware marijuana is not an approved therapeutic agent in Canada;
• I wish to consider the use of marijuana as medicine despite potential side effects;
• I have a medical condition (diagnosis) that may benefit from marijuana;
• I am legally able to make all of my health decisions on my own;
• I agree not to make any claim or commence any proceedings against MedicannaExpress.ca / my family physician / or any other involved physicians in relation to my use of marijuana (cannabis / cannabinoids);
• I do not support any claims made by my family, friends or other interested parties against MedicannaExpress.ca and physicians. I release MedicannaExpress.ca / my family physician / any other involved physicians 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 marijuana (cannabis / cannabinoids). This release from liability is to be binding on heirs, executors and assigns.

SIDE EFFECTS CONSENT (I declare the following to be true):
• I acknowledge there has only been limited research into the safety of marijuana and that the safety and efficiency of dried marijuana for medical purposes has not been established. No notice of compliance has been issued for marijuana in Canada. I understand and accept the following possible consequences of marijuana use including but not limited to: impaired judgment, anxiety, paranoia, sedation, decreased inhibitions, drug tolerance, possible dependence, possible withdrawal symptoms, the need for possible drug holds, an increase in appetite leading possibly to weight gain, an impaired immune system, interaction with other drugs, the possible need to decrease the dose of some medications (with the supervision of my primary care physician), dysphoria (an unpleasant emotional state), depleted energy, impaired short term memory, and lung damage (smoked form);
• I acknowledge that all of the potential health risks associated with marijuana may not yet have been identified and that marijuana may have an adverse effect on my health in the future;
• I acknowledge the use of marijuana may have an effect on my motor skills. Consequently I will not operate a motor vehicle, handle machinery or perform other risky activities if impaired with marijuana;
• I understand that the use of marijuana may be dangerous during pregnancy. I agree to notify my primary care practitioner if I have any significant side effects arising from my use of marijuana.