New Patient Form
Emergency Contact *
Current Medication Status (optional)
I certify that the above information is correct. I understand my information is protected by Federal and State Laws and will not be disclosed to anyone outside of The Nirvana Center or the Arizona Department of Health Services without my written consent.
Medical Marijuana Acknowledgment of Disclosure and Informed Consent
Please read below and sign to indicate that you understand and agree you have been advised of the health risks of medical marijuana.
By signing, you understand and agree with the information. If you have questions or do not understand the information below, consult
with a dispensary employee before initialing or signing this agreement. Please do not sign this agreement and do not use medical
marijuana if you do not understand the following information you have received. I understand that medical marijuana is a medicine
used in treating the suffering caused by serious and debilitating medical conditions. Serious and debilitating medical conditions
include cancer, HIV, nausea, arthritis, chronic pain, glaucoma, cachexia, migraine headaches, anorexia, seizures, and persistent muscle
spasms. Additionally, medical marijuana is used in the treatment of other chronic or persistent symptoms that:
Please provide your signature stating you have been advised of the health risks associated with medical marijuana and will
not hold Jamestown Center, Inc liable for any side effects that you may experience or any legal consequences that may arise due
to medical marijuana purchased at this dispensary.