THE QUALIFIED PATIENT OR THE PATIENT’S PARENT OR LEGAL GUARDIAN IF THE PATIENT IS A MINOR MUST SIGN THIS INFORMED CONSENT FORM TO INDICATE THAT THE PATIENT UNDERSTANDS AND ACCEPTS THE INFORMATION.
A. Provider-Patient Relationship
Patient understands that he or she is entering into a provider-patient relationship with the health professionals at Utah Therapeutic Health Center LLC (UTTHC LLC).
B. Controlled Substance
The federal government has classified marijuana (or cannabis) as a Schedule I controlled substance. Schedule I substances are defined, in part, as having (1) a high potential for abuse; (2) no currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution, and possession of marijuana even in states, such as Utah, which have modified their state laws to treat marijuana as a medicine.
When in the possession or under the influence of medical marijuana, the patient or the patient’s caregiver must have his or her medical cannabis patient card in his or her possession at all times.
C. Food and Drug Administration
Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore, the “manufacture” of marijuana for medical use is not subject to any federal standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients, which may vary in potency, impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.
D. Potential for Addiction
Some studies suggest that the use of marijuana by individuals may lead to a tolerance to, dependence on, or addiction to marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I should contact my provider at UTTHC LLC.
E. Potential Effect on Coordination, Motor Skills, and Cognition
The use of marijuana can affect coordination, motor skills, and cognition, i.e., the ability to think, judge and reason. Driving under the influence of cannabis can double the risk of crashing, which escalates if alcohol is also influencing the driver. While using medical marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly and I should not participate in activities that may be dangerous to myself or others. I understand that if I drive while under the influence of marijuana, I can be arrested for “driving under the influence.”
Upon request of the patient, UTTHC LLC may be able to provide services that can test THC levels in the body and the patient’s cognitive ability and coordination.
F. Potential Side Effects
Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory, euphoria, difficulty in completing complex tasks, suppression of the body’s immune system, may affect the production of sex hormones that lead to adverse effects, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of medical marijuana may cause me to talk or eat in excess, alter my perception of time and space and impair my judgment. Many medical authorities claim that the use of medical marijuana, especially by persons younger than 25, can result in long-term problems with attention, memory, learning, drug abuse, and schizophrenia.
I understand that using marijuana while consuming alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana.
I agree to contact UTTHC LLC, if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact UTTHC LLC, if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends.
G. Risks, Benefits, and Drug Interactions of Marijuana
Signs of withdrawal can include: feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.
Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to Contact UTTHC LLC, immediately, or go to the nearest emergency room.
Numerous drugs are known to interact with marijuana and not all drug interactions are known. Some mixtures of medications can lead to serious and even fatal consequences. I agree to follow the directions of UTTHC LLC regarding the use of prescription and non-prescription medication. I will advise any other of my treating medical provider(s) of my use of medical marijuana.
Marijuana may increase the risk of bleeding, low blood pressure, elevated blood sugar, liver enzymes, and other bodily systems when taken with herbs and supplements. I agree to contact UTTHC LLC immediately or go to the nearest emergency room if these symptoms occur.
I understand that medical marijuana may have serious risks and may cause low birth-weight or other abnormalities in babies. I will advise UTTHC LLC if I become pregnant, try to get pregnant, or will be breastfeeding.
H. Use of Patient’s De-identified Health Information for Research Purposes
The Department of Health may release limited patient data it collects for the purpose of medical research or other official department purposes. This data may include the patient’s qualifying medical condition, medicinal dosage form and amount, the quantity and type of cannabis, cannabis product, or medical cannabis device purchased, and time and date of purchase.
I. Cannabis Product
UTTHC LLC has informed me that it is not the grower or producer of any medical cannabis product, and cannot guarantee the effectiveness, THC levels, or any other aspect of the medical cannabis product its providers recommend or that is provided by the pharmacy.
I have had the opportunity to discuss these matters with the medical provider and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge that UTTHC LLC has informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana.
UTTHC LLC also informed me of the risks, complications, and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that UTTHC LLC informed me of alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits.
J. Donating to Uplift
Donations to Uplift are voluntary and do not entitle donors to any benefits from UTTHC.
UTTHC reports all raised funds and patient visits subsidized on UtahMarijuana.org/uplift manually. The reported number of visits subsidized represents patients who have been notified of their approval to receive an Uplift subsidy.
Utah Therapeutic Health Center, WholesomeCo Cannabis, Deseret Wellness, Zion Medicinal, Perfect Earth Modern Apothecary, and Bloc Pharmacy each match up to the first $1000 donated in each calendar month, dollar-for-dollar. After $1000 is raised, further donations in the month are not matched.
UTTHC uses donation and donation-matched funds to pay clinic fees for patients who apply and qualify for Uplift. On occasion, some funds may be used toward Uplift program administration and materials to sustain the program.
By donating to Uplift, I acknowledge and agree to these terms.