PATIENT INTAKE FORM
As a qualied patient protected by California law (Health and Safety Code§11362.5 and §11362.7, et seq.,CA SB420) your are required to read and agree with the following statements to become a member of Bud & Bloom Dispensary, a California non-prot association:
I hereby declare under penalty of perjury under the laws of the state of California that I am a California resident over the age of 21, have a valid state issued Driver’s License or Identication Card and a valid written approval by a licensed California physician to use medical marijuana for my documented medical condition(s).
- I understand that Bud & Bloom Dispensary is a California non-prot association of qualied patients who voluntarily joined together to share resources and cultivate medical marijuana for each other’s respective medical condition(s). As a qualied patient, I choose to become a member of Bud & Bloom Dispensary.
- I understand that Bud & Bloom Dispensary was established to provide a professionally administered and legally structured collective for benetof all its members.
- As a member, I appoint and designate Bud & Bloom Dispensary and their representatives as my true and lawful agents for the limited purpose of assisting in obtaining medical marijuana. I understand this means that Bud & Bloom Dispensary may be required to cultivate, purchase, possess, transport and distribute my medication to me and I grant them authority to do so.
- I understand that Bud & Bloom Dispensary operates within full compliance of all applicable California Laws relating to the cultivation, possession, transportation and use of medical marijuana.
- I understand that all donations made to Bud & Bloom Dispensary are to be used to reimburse for actual expenses and reasonable costs for administration of the collective. Furthermore, all donations are for the continued operation of the collective and that any said donation in no way constitutes a commercial promotion or sale of any item.
- I understand that Bud & Bloom Dispensary will keep a copy of my California physicians’s recommendation for medical marijuana use on le and I agree to provide my California Driver’s License or California Identication Card each and every time I obtain medical marijuana.
- I agree that only myself, or my designated caregiver will interact with Bud & Bloom Dispensary staff.
- I agree to not share, sell or distribute any medical marijuana I obtain through Bud & Bloom Dispensary.
- I agree that weapons, illegal drugs or activities are not allowed at the dispensary.
- I agree to contact Bud & Bloom Dispensary if there are any changes to my address, phone number, physician, caregiver or email.
- I understand this is a bi-lateral Membership Agreement. Either myself or Bud & Bloom Dispensary, may terminate this Membership Agreement at any time, by email, without notice or reason and the other party to this membership Agreement has absolutely no recourse or basis to reinstate the Membership Agreement or any course of legal action.
- Notice to Patrons:
- Use of medical marijuana shall be limited to the patient identied on the doctor’s recommendation. Secondary sale, barter or distribution of medical marijuana is a crime and can lead to an arrest.
- The loitering on and around the collective site is prohibited by California Penal Code 647(e) and that patrons must immediately leave the site and not consume medical marijuana in the vicinity of the collective or on the property or in the parking lot.
- Forgery of medical documents is a felony crime.
- A warning that patrons may be subject to prosecution under federal marijuana laws.
- We request that all members treat fellow members and sta with respect at all times.
- That the use of medical marijuana may impair a person’s ability to drive a motor vehicle or operate machinery.
- Oensive, abusive, threatening, hostile, or derogatory language will NOT be tolerated at the dispensary.
- No food/drink or any kind of soliciting is allowed inside the dispensary.
- No alcohol, other controlled substances, or weapons are allowed in the dispensary.
- All prices include applicable sales tax.
I have read, understand and agree to all the above: