Ermont, Inc.

New MA Medical Patient Acknowledgement Form


Patient Acknowledgement Form


I have not applied for nor received a hardship cultivation registration. *
I understand that my registration card only allows me to possess and use marijuana for medical purposes within Massachusetts. *
I understand marijuana has not been analyzed or approved by the FDA, including marijuana produced by ERMONT, Inc. *
I understand there is limited information on the side effects of marijuana, including marijuana produced by ERMONT, Inc. *
I understand there may be health risks associated with using marijuana, including marijuana produced by ERMONT, Inc. *
I understand marijuana, including marijuana produced by ERMONT, Inc., should be kept away from children. *
I understand that when under the influence of marijuana, driving is prohibited by M.G.L. c. 90, s. 24, and machinery should not be operated. *
I understand I may not distribute marijuana to any other individual, and must return unused, excess, or contaminated product(s) purchased at ERMONT, Inc., to an ERMONT, Inc. dispensary for disposal. *
I agree at all times to abide by Massachusetts law in regards to my use of medical marijuana, and hereby release and waive all claims against ERMONT, Inc. from any and all liability related to my use of medical marijuana. *
I agree not to bring any weapons or anything that can be used as a weapon into ERMONT, Inc. facilities. *
I agree to the use of medical marijuana in a way that does not endanger the health and well being of any person. *
I understand that ERMONT, Inc. may refuse to dispense medical marijuana to me if in the opinion of the dispensary agent, the public or myself will be placed at risk by so doing. In this event I understand that my certifying physician will be notified within 24 hours. *
I have been offered the ERMONT, Inc. patient handbook. *
How did you hear about us? *
Check all that apply
Name *
Name
Date *
Date
Phone *
Phone
Signature (we will collect on your first visit)