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					ACKNOWLEDGEMENTS OF RISKS AND LIABILITIES I______________________________________________ of the following: Patient/Minor Patient’s Parents or Legal Guardians 1) 2) 3) 4) have been informed by Dr. Paoletti

The use of medical marijuana is of unknown benefit The use of medical marijuana creates unknown risks The use of medical marijuana may be harmful The use of medical marijuana is not government regulated by the Federal Food and Drug Administration for medical purposes and may contain unknown quantities of active ingredients and potentially contain contaminants and /or impurities that may be harmful to my health. 5) The use of medical marijuana is forbidden under Federal Law. 6) There may be very little scientific information available about the usage of medical marijuana. 7) Dr Paoletti may not be knowledgeable of all the associated risks involved in the use of medical marijuana. I acknowledge that Dr. Paoletti has informed me that using medical marijuana while using heavy machinery or engaging in potentially hazardous activities is unsafe. Should I engage in the illegal or legal use of medical marijuana, I will assume full responsibility for any harm resulting to me and /or other individuals as a result of my driving or engaging in potentially hazardous activities while under the influence of medical marijuana. I acknowledge that there may be unanticipated side effects/symptoms involved with medical marijuana use. I also assume full responsibility for the reporting of any and all adverse effects/symptoms to my primary care physician and Dr. Paoletti should these adverse side effects/symptoms occur in relation to any illegal or legal use of medical marijuana. I acknowledge that there have been no FDA approved studies in regards to cannabis use during pregnancy and the safety of using cannabis during pregnancy is unknown. I therefore, if female, I agree to abstain from cannabis use both legal or illegal, if 1) a period is missed, 2) a positive pregnancy test has occurred, or 3) unprotected sex with a fertile partner during reproductive age is occurring. I understand that although medical marijuana is legal in the state of California, it is forbidden by federal law and that Dr. Paoletti, by issuing a medical recommendation for marijuana, is in no way, encouraging the violation of Federal law. I hereby assume full responsibility for the use of this recommendation and I, the undersigned, my heirs, assignments, or anyone acting on my behalf, hold the physician and his/her principals, agents and employees, free of and harmless from any liability resulting from the use of the medical marijuana letter or the illegal or legal use of cannabis. __________________________________________date__________________ Patient/minor patient’s parent or legal guardian ___________________________________________date__________________ Physician DR CHRISTINE PAOLETTI, SANTA MONICA, CA 90404