NEW PATIENT INTAKE PACKET

Thank you for your interest in our clinic. During your first
visit, you’ll be required to supply us with a valid Texas driver’s
license or state ID card. If you do not possess a valid Texas driver
license or Texas identification card, you may submit a copy of a
utility bill in your name including a Texas address, or a Texas voter
registration card.

To streamline your initial appointment, we ask that you print,
read, and complete each form within this packet prior to your
scheduled visit.

The forms and paperwork included are:

• Informed Consent

• Medical Cannabis Patient Agreement

• Telemedicine Consent

• Medical History

• Medical Records Release

• Cancellation/ No Show Policy

We would like to see your most current medical records from the last 12 months. You can ask your current primary care physician or specialist to fax or email us a copy of your records. Our fax number is 832-831-1882. You can print and complete our medical records form included within this packet and give it to your current doctor. Note that your doctor’s office may charge you to send us records.

If you are unable to complete or print this packet at home, you’ll need to fill out all of this information prior to being seen by the doctor. Please call us at 713-955-3325 or email us at info@TexasHerbalClinic.com if you have questions or issues.

Medical Cannabis Acknowledgement of Disclosure and Informed Consent

Please read each item below and initial in the space provided to indicate that you understand and agree with the information regarding the risks and side effects of using Medical Cannabis. Do not sign this agreement and do not use Medical Cannabis if you have questions about or do not understand the information you have received. Please tell us if you do not understand any of the information provided.

WARNINGS:

I am being evaluated for a physician's order for Medical Cannabis. The physician will make this order based, in part, on the medical information I have provided. I hereby acknowledge that I have not misrepresented my medical condition to obtain this recommendation and it is my intent to use Medical Cannabis only as needed for the treatment of my medical condition, not for recreational or non- medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of Medical Cannabis. I have been informed of and understand the following:

I understand that possession or use of Medical Cannabis is unlawful under Federal law and outside of the state of Texas. I also understand that possession or use of Medical Cannabis is unlawful within the state of Texas if not recommended for medical purposes by a licensed medical doctor with the legal ability to do so.Certain forms of Medical Cannabis may have intoxicating effects and has not been analyzed or approved by the United States Food and Drug Administration and was produced without FDA oversight for health, safety, or efficacy. Medical Cannabis may contain unknown quantities of active ingredients, impurities, or contaminants.The efficacy and potency of Medical Cannabis may vary widely depending on the strain and ingestion method.If Medical Cannabis is vaporized: Such use may be hazardous to your health. Medical Cannabis contains carcinogens and can lead to an increased risk for cancer, tachycardia, hypertension, heart attack, birth defects, brain damage, and lung disease.If Medical Cannabis is eaten or swallowed: This product has been infused with cannabis or active compounds of cannabis. When eaten, or swallowed, the intoxicating effects of this drug may be delayed by two or three hours or more.There is limited information on the side effects of using Medical Cannabis, and there may be associated health risks.Symptoms of Medical Cannabis overdose include but are not limited to nausea, vomiting and disturbances to heart rhythm.For some patients, chronic Medical Cannabis usage can lead to laryngitis, bronchitis, and general apathy.I understand side effects of Medical Cannabis can include but are not limited to:Memory loss, Irregular heartbeat, Slower reaction time/inability to concentrate, Poor physical condition, Cough/bronchitis/shortness of breath, Dizziness, Impaired vision, Drowsiness/fatigue/abnormal sleep, Depression, Laryngitis, Low blood pressure, Impairment of motor skills, Anxiety/Nervousness, Dry mouth, Suppression of immune system, Hunger/Loss of appetite, Dependency, Confusion, Feelings of euphoria, Headache/nausea/vomiting, Numbness, Agitation, Paranoia/psychotic symptoms, SedationThe scientific basis for the medical use of Medical Cannabis is not complete. There is little known regarding how Medical Cannabis may, or may not, react with other pharmaceutical or herbal medications.Some patients can become dependent on Medical Cannabis. This means they experience withdrawal symptoms when they stop using Medical Cannabis. Signs of withdrawal symptoms can include feelings of depression, sadness or irritability, restlessness or mild agitation, insomnia, sleep disturbance, unusual tiredness, trouble concentrating, and loss of appetite.Some users develop a tolerance to Medical Cannabis. This means higher and higher doses are required to achieve the same symptom relief.The possibility exists that Medical Cannabis may exacerbate schizophrenia in persons predisposed to that disorder.Women should not consume Medical Cannabis while planning to become pregnant, during pregnancy, or while breast feeding, except on the advice of the certifying health practitioner, and in the case of breastfeeding mothers, on the advice or the infant’s pediatrician.Using Medical Cannabis while under the influence of alcohol is not recommended.The use of Medical Cannabis may affect coordination, cognition, and judgment. While under the influence of Medical Cannabis, do not to drive, operate machinery, or engage in potentially hazardous activities.Please note that Medical Cannabis will degrade over time. Always keep out of reach of children and pets.

Medical Cannabis Patient Agreement

I am over 18 years of age and understand the requirements of the State of Texas Medical Cannabis program.I have been advised of the current state of knowledge in the medical community of the effectiveness of Medical Cannabis for the treatment of my condition.I have been advised of the potential risks and side effects of using Medical Cannabis.I have been advised of the medically acceptable alternatives.I have read and understand the foregoing disclosures and have marked next to each one acknowledging this understanding.I have been further advised that some forms of Medical Cannabis may contain chemicals known as tars that may be harmful to my health.I understand that side effects may occur while I am taking Medical Cannabis.In the event that I experience an adverse reaction, I am advised to contact my medical professional. In the event my medical professional is not available, I agree to call 911 for help and I am advised to lie down, relax, and rest until help arrives.I have never had symptoms of schizophrenia or have been diagnosed as having schizophrenia by a physician or mental health professional.I have no direct blood relatives (father, mother, siblings) that have had symptoms or has been diagnosed as having schizophrenia or has been psychotic.I agree to tell my medical professional if I have ever had symptoms of schizophrenia, been psychotic or attempted suicide. I also agree to tell my medical professional if I have ever been prescribed or taken medicine for any of these problems.I understand that my medical professional does not suggest nor condone that I cease treatment of medications that stabilize my mental or physical condition.I am not pregnant, intending on becoming pregnant, or breastfeeding.When under the influence and/or in possession of Medical Cannabis in public, your state issued Medical Cannabis ID Card or temporary state issued verification should be on your person at all times.I understand if I give dishonest or untruthful information, I will be discharged.I understand I must give 48-hours notice for cancellation of appointments. I further understand that 2 or more no calls/no shows within a calendar year will result in my discharge from the practice as well as possible revocation of patient recommendation.I understand there are certain requirements to remain in compliance with Texas law regarding Medical Cannabis. Some of these requirements include (but are not limited to): • Patient establishment within our practice for 90 days • Regularly scheduled follow-ups at intervals determined by state lawI understand that the Department of Health may revoke a Compassionate Use Registry identification card for any of the following: (a) The patient or legal representative makes material misrepresentations in his or her application. (b) The patient uses his or her card to obtain cannabis for another individual (c) The legal representative purchases, obtains, possesses, or uses cannabis not sold by an approved dispensing organization, or (d) The patient is no longer a qualified patient.I further understand that if I am not in compliance with state law and regulations set fourth and enforced by the Office of Compassionate Use, my order may be revoked.If I start taking Medical Cannabis, I agree to tell my medical professional if I experience (any one or more of the following):Start to feel sad or have crying spells Have changes in my normal sleep patterns Lose my appetite Become more irritable than usual Become unusually tired Withdraw from family and friends Lose interest in my usual activities

Release of Liability

I hereby acknowledge Texas Herbal Clinic and its employees are not addressing specific aspects of my medical care nor are any of them my primary care provider. Furthermore, I, for myself, my heirs, assigns, or anyone acting on my behalf, hold Texas Herbal Clinic and its principals, agents, and employees free of and harmless from any responsibility for any harm resulting to me and/or other individuals because of my Medical Cannabis use.I certify that I fully understand the potential risks and side effects related to the use of Medical Cannabis as described above.In using Medical Cannabis, I fully accept responsibility and assume the risks and side effects associated with its use.I agree that Texas Herbal Clinic and employees shall not be held responsible for any harm resulting to me and/or any other individual(s) because of my use of Medical Cannabis.I certify that I have read this document and declare under penalties of perjury that the information contained herein is true, correct, and complete.

Qualifying Conditions

Your Qualifying Conditions for the “Texas Medical Cannabis Program”

to release and discuss any and all medical records and medical information that you have for me in your possession regarding my medical condition and my medical treatment, including but not limited to, my medical history, my medical treatment, your findings regarding my medical condition, records of consultations that I have had, records of medication prescribed for me, x-rays taken of me, my radiology reports, and hospital, and medical records to:

for the sole purpose of medical records review and certification of my medical condition.

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information.

This authorization is intended to be an unlimited, full, and complete Authorization for the release of any and all protected medical information as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Medical Records Access Act, as amended, and under the rules and regulations thereof, and covers all protected information from primary and secondary providers, health plans, health care clearinghouses, emergency services, financial and administrative transactions, and business associates. A covered entity may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization when the prohibition on conditioning of authorizations in 45 CFR 164.508(b) (4) applies. It is understood that the person to whom this Authorization is given has my permission to use and disseminate this information in his or her sole discretion.

1. Expiration. This authorization expires 18 months after patient signed this release.

2. Right to Revoke. I have the right to revoke this authorization by signing and dating a written statement revoking this authorization, and it shall become effective on delivery to you. If this authorization is revoked, any person or entity acting in good faith in reliance upon it and lacking actual knowledge of its revocation shall be held harmless.

3. Redisclosure. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected by this rule.

4. Administrative Provisions. I revoke any prior authorizations I have made to disclose health information that are inconsistent with this authorization. This document shall be governed by Texas law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub L No 104-191, and the Medical Records Access Act, MCL 333.26261 et seq. However, I intend it to be honored in any jurisdiction where it is presented and for other jurisdictions to refer to Texas law and HIPAA to interpret and determine the validity and enforceability of this document. Photocopies or facsimile reproductions of this signed authorization shall be treated as original counterparts. I am providing this authorization voluntarily and have not been required to give it to obtain treatment. I am at least 18 years old and of sound mind.

5. Any Billing for Medical Records is solely the patient's responsibility

Cancellation/No Show Payment Policy

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise when another patient fails to cancel and we were unable to schedule you for a visit, due to a full schedule.

Cancellations

It is our policy that all appointments must be cancelled at least 48 hours in advance of the appointment. If an appointment is not cancelled 48 hours in advance, you will be charged the full appointment cost. All patients will have the opportunity to show proof of an "urgent" reason as to why they were unable to make their scheduled appointment. Upon doing so, the patient will not be charged for the late cancellation.

No Show

Patients who "No Show" their visit will be charged for that visit and will be required to pay before being seen, again. All patients will have the opportunity to show proof of an "urgent'' reason as to why they were unable to make their scheduled appointment.

Scheduled Appointments

We understand that delays can happen, however, we must try to keep the other patients and doctors on time. We request you come 30 minutes early to your appointment to account for traffic and to complete the required paperwork. If you are 15 minutes past your scheduled time, your provider may not be able to complete a full visit or we will do our best to accommodate you and fit you into the schedule later in the day. If you cannot complete your visit you will be charged for the full visit and you will be required to book a new visit.

Account Balances

We will require that patients pay their account balances to zero (0) prior to receiving further services by our practice. We also require payment be rendered prior to services.

Acknowledgement of Receipt of Cancellation/No Show Policy