Patient Consent and Waiver of Liability

I, the undersigned, agree not to make any legal claim or complaint or commence any proceeding againstDr Joel
Durinka (hereinafter referred to as “Physician”), in providing me with a physician certification and/or registering me
with the Department of Health Medical Marijuana Program Patient Registry pursuant to Title 310 of the Oklahoma
State Department of Health and Chapter 681 of the Medical Marijuana Control Program.

I am hereby giving voluntary informed consent to treatment with medical cannabis. The

has sufficiently explained the current state of knowledge in the medical communitythe effectiveness of treatment of
my condition with medical cannabis, the medicallyalternatives, and the potential risks and side effects. I understand
that there aretreatment options and I am not obligated to seek treatment with this Physician.

I release this Physician from any and all actions, causes of actions, claims, complaints, and demands for damages, loss
of life, injury, economic or employment loss, positive results on drug screens, damage to reputation or character,
termination of service or care by another healthcare professional, or whatsoever arising directly or indirectly as a
result of my use of Medical Cannabis.

I hereby affirm I am assuming all risks associated with the use of medical cannabis, both foreseeable and
unforeseeable, that may occur now or anytime in the future.

The Federal Food and Drug Administration (FDA) approves all drugs prescribed by physicians, Cannabis is not an FDA
approved medication. The use of cannabis in any form has not been evaluated by the FDA. The use of cannabis is not
intended to diagnose, treat, or cure any disease.

The certification of a qualifying condition by this Physician does not constitute a prescription to use medical cannabis.
The decision to use medicinal cannabis should not be based solely on this Physician’s certification. The patient is
advised to consult with their primary care physician, private legal counsel, and perform their own independent
research before using medical cannabis.

The Physician cannot write a prescription for medicinal cannabis and has no control over the content of the
medication. The effects or the adverse risks of whichever medicinal cannabis product you decide to consume vary
from patient to patient.

The Physician may not be able to provide you with thoroughly researched conclusions regarding all the potential
benefits and adverse risks of medicinal cannabis use for your qualifying medical condition. The scientific research on
cannabis is incomplete and does not meet the high requirements for all other medicines approved by the FDA.

The Physician may enter a dose and route order for the use of medicinal cannabis. You are solely responsible for
administering medicinal cannabis as your condition warrants, as determined by your own judgement and are solely
responsible for all the consequences.

Medicinal cannabis is generally well tolerated by patients. If

Leonard Doolan a route/dose is not entered by the Physician, the patient will
Patient Name be referred to discuss dosing and administration with a
qualified professional at a Oklahoma approved dispensary.
Any side effects tend to be mild and temporary, usually lasting one week or less as patients adjust. Common side
effects include irritated throat, dry mouth, elevated heart rate, mild time and space disorientation, mild euphoria, a
general sense of well-being, and in some instances, drowsiness and decreased motivation. Any side effects must be
reported to the Physician at the follow up visit, or as needed during the interim. There is a very rare, but potentially
serious, side effect known as “First Dose Psychosis” that may occur with initial exposure to medicinal cannabis. Should
respiratory problems or other ill effects be experienced in association with the use of medical marijuana, I agree to
discontinue its use and report any or report such problems or effects to the attending physician. Although smoking
marijuana has not been linked to lung cancer, smoking marijuana can cause respiratory harm, such as bronchitis.
Many researchers agree that marijuana smoke contains known carcinogens (chemicals that can cause cancer), and
that smoking marijuana may increase the risk of respiratory diseases and cancers of the lungs, mouth and tongue. I
have been advised that cannabis (medical marijuana) smoke contains chemicals known as tars that may be harmful to
my health. Vaporizers may substantially reduce many of the potentially harmful smoke and toxins that are normally
my health. Vaporizers may substantially reduce many of the potentially harmful smoke and toxins that are normally
present in marijuana smoke.

I acknowledge that the Physician will immediately deactivate and revoke my medical cannabis recommendation if I
am arrested for, charged with, and/or convicted of any cannabis related activities. I acknowledge that the Physician
will not testify on my behalf for a medically necessary defense related to any criminal cannabis charges or other
criminal or civil matters. Revocation of the Physician Certification will represent an immediate termination of the
patient-physician relationship. Furthermore, I release the Physician from all subpoenas, interrogatories, attestations,
or testimonies related to any criminal cannabis charges or other criminal or civil matters. I agree to not require
Physician to fill out any releases, clearances, forms from employers, or any other paperwork other than that which is
required for your certification in the Oklahoma Medical Marijuana Program.

If I request changes or amendments to my recommendation, I understand a follow-up visit is required with Physician
which could be subject to an additional out-of-pocket expense.

This release of liability is to be binding on my heirs, executors, and assigns. I have read, understand and agree with all
statements in this Waiver of Liability.

Patient Signature

EquoSign - eSignature
Signed by: Leonard Doolan

Signed on: 05/02/2023

Leonard Doolan
MjAyMy0wNS0wMiBEb29sYW4=

Certifications
I certify the information provided to the Physician is true and accurate to the best of my knowledge.

Any person who fraudulently submits false, misleading, or inaccurate information to the Physician for the purpose of
being recommended medical cannabis by such Physician commits a misdemeanor under Oklahoma law, may be
subject to prosecution, and will be removed from the Department of Health Medical Marijuana Program Patient
Registry.

I additionally certify that I have been given actual Notice and understand that, notwithstanding Title 310 of the
Oklahoma State Department of Health and Chapter 681 of the Medical Marijuana Control program:

1. Cannabis is a prohibited Schedule I controlled substance under Federal law. The Act does not provide any immunity
from or affirmative defense to arrest or prosecution under Federal law;

2. Participation in the program is permitted only to the extent provided by the strict requirements of Title 310 of the
Oklahoma State Department of Health and Chapter 681 of the Medical Marijuana Control Program;

3. Any activity not sanctioned by the Act may be a violation of State or Federal law and could result in arrest,
conviction, or incarceration;

4. Growing, distributing, or possessing cannabis in any capacity, except through a federally approved research
program, may be a violation of State or Federal law and could result in arrest, conviction, or incarceration;

5. Use of medical cannabis, or possessing a cannabis patient registry card, may affect an individual’s ability to receive
or retain Federal or State licensure and other areas;

6. I agree to tell the attending physician if I have ever had symptoms of depression, been psychotic, attempted suicide
or had any other mental problems. I also agree to tell the attending physician if I have ever been prescribed or taken
medicine for any of the conditions stated above. Furthermore, I understand that the attending physician does not
suggest nor condone that I cease treatment and or medication that stabilize my mental or physical condition.

7. Little is known regarding short- and long-term effects of cannabis on mother and baby during pregnancy, and while
breastfeeding. I understand that Physician has advised me, and I have agreed to, not use cannabis while pregnant or
breastfeeding.

8. Medical cannabis should NOT be used when operating a vehicle, vessel (e.g. boat) or machinery.

Patient Signature Physician Signature

EquoSign - eSignature EquoSign - eSignature

Signed by: Leonard Doolan Signed by: Dr Joel Durinka

Signed on: 05/02/2023 Signed on: 05/02/2023

Leonard Doolan
MjAyMy0wNS0wMiBEb29sYW4= MjAyMy0wNS0wMiBEdXJpbmth

296064
Physician License Number

2215 SOUTH EL CAMINO REAL, SUITE 205 SAN MATEO, CA 94403

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