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Patient Consent Template 1 -Form Fill

Section One
Q1

Acknowledgement*
Q2

Marijuana as a Schedule I controlled substance*
Q3

Potential abuse or addiction*
Q4

Psychological Effects*
Q5

Side Effects*
Q6

Alcohol*
Q7

Overdose*
Q8

I hereby declare that I am of legal age and can freely give my consent to the legally binding terms and conditions to this form.
Q9

Name of Patient

First Name
Q10

Name of Patient

Last Name
Q11

Signature of Patient
Q12

Date Signed

Date