Membership Patient Agreement

  • As a qualified patient protracted by California Law, Health & Safety Code 11362.5 and 1136.7 at seq. and in conjunction with California State Senate Bill 420, you are required to read and agree to the following statements to become a member of The Healing Touch, Inc. Please understand that these are for your protection, as well as ours. Please read the following statements and initial that you have read and understand each statement, then sign at the end of the form. Thank you!
  • I hereby declare that i am a qualified patient under Ca H&S code 11362.5 , 11362.7 et seq, and my doctor has recommended, prescribed and approve my use of medical marijuana. As per CA H&S code 11362.51, I am legally able to use, possess and cultivate cannabis for medical purposes. i understand that i am allowed to do so through safe and affordable access such as the type provided by The Healing Touch, Inc. I, therefore, designate The Healing Touch, Inc. as my care provider for this purpose and in doing so i agree to sign and follow all The Healing Touch rules and regulations regarding their service. I also agree to pay all personal out of pocket expensive and reasonable compensation for the The Healing Touch, Inc. member services.
  • I herby declare under penalty of perjury under the law of the state of California that a medical doctor has recommended, prescribed or approved my use of medical marijuana and i have been diagnosed with a serious illness for medical cannabis relief.
  • I hereby verify that I am a California resident and my personal medical marijuana will not be taken out of the state of California. I further verify and agree that my medical marijuana shall not be shared, sold, bartered, traded, exchanged or delivered in any other means to other person.
  • I hereby declare and understand that my contributions to The Healing Touch, Inc. for and through prescribed medicinal products that I may acquire from The Healing Touch, Inc. are used to ensure the continued operation of The Healing Touch, Inc. and that any transaction in no way consist of a commercial promotion or sale of any item.
  • As a member, I herby agree, appoint and designate The Healing Touch, Inc. and their representatives, as my true and lawful agents for the limited purpose of assisting me in obtaining my legally prescribed medicinal marijuana. I understand this means The Healing Touch, inc. will be required to purchase, possess, transport an distribute my medication to me as prescribed by my physician and i grant them the limited authority to do so. I further authorize The Healing Touch, Inc. to enter whatever agreements are necessary with growers or other medicinal providers, as my duly authorized primary caregiver, to assist me with obtaining my medications.
  • As a member, I understand that The Healing Touch, Inc. to has other members with similar membership agreements. I hereby authorize The Healing Touch, Inc. to jointly posses the medical marijuana as described under this agreement with other The Healing Touch, Inc. members under similar membership agreements. I agree the medical marijuana possessed by The Healing Touch, Inc. at any time is the collective property of every patient who is also under the membership agreement and the care of The Healing Touch, Inc.
  • I agree to possess my original or a true and corrective copy, of my recommendation/prescription when i am on The Healing Touch, Inc. property. Understand that my failing to do so may result in refusal of services. I hereby agree to all future changes of these policies as the laws for safe access develop. I agree that any violation of the terms of this agreement or any other club rules are grounds for immediate termination of my membership.
  • I agree to provide The Healing Touch, Inc. with all changes in my contact information, diagnosis, or primary physician immediately.
  • Any patient who commits or threatens an act of violence to the delivery driver will be excluded from membership and may be subject to criminal prosecution.
  • I hereby affirm that i have read, understand and agree to the terms of The Healing Touch, Inc. membership agreement.

Medical Release

I hereby authorize my treating Physician, as required by the State and Federal laws including HIPPA regulation, to release my medical information concerning my diagnosis, condition and/or prescription to The Healing Touch, Inc and its duty authorized representatives

The Healing Touch Enrollment Form

Prescribing Physician's Information

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