By checking this box/submitting this form, I understand and agree that zazaMD, inc d/b/a ZazaMD will share my information with a third party physician or medical practice, and that third party physician or medical practice may in turn share my information, including his or her recommendation, if one is provided, with ZazaMD.

Informed Consent: I am being evaluated for a physician’s recommendation for medical use of marijuana. The physician will make this recommendation based, in part, on the medical information I have provided. I have not misrepresented my medical condition in order to attain this recommendation and it is my intent to use marijuana 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 marijuana. I have been informed of and understand the following:

1. The federal government has classified marijuana as a Schedule 1 controlled substance. Schedule 1 substances are defined, in part, as having 1) a high potential for abuse; 2) no currently accepted medical use in treatment in the United States; and 3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution and possession of marijuana even in states, such as California, which have modified their state laws to treat marijuana as a medicine.
2. Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore the “manufacture” of marijuana for medical use is not subject to any standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients (i.e., can vary in potency), impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.
3. The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. While using marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly. I understand that if I drive while under the influence of marijuana, I can be arrested for “driving under the influence.”
4. Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory, euphoria, difficulty in completing complex tasks, suppression of the body’s immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness. Marijuana may exacerbate schizophrenia in person predisposed to that disorder. In addition, the use of marijuana may cause me to talk or eat in excess, alter my perception of time and space and impair my judgment. Many medical authorities claim that use of cannabis, especially by persons younger than 25, can result in long term problems with attention memory learning a tendency for drug abuse and schizophrenia. Cannabis use is recommended only for the relief of serious symptoms and not for habitual use.
5. I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become president when using both alcohol and marijuana. Cannabis should be treated as an open container of alcohol. It should not be within reach in the car and should not be extinguished in the vehicle’s ashtray.
6. I agreed to contact my medical provider if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact my medical provider if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, and increased irritability or begin to withdraw from my family and or friends.
7. Smoking marijuana may cause respiratory problems and harm including, bronchitis emphysema, and laryngitis. In the opinion of many researchers marijuana smoke contains known carcinogens (chemicals that can cause cancer) and smoking marijuana may increase the risk of respiratory diseases and cancers in the lungs, mouth, and tongue. In addition, marijuana smoke contains harmful chemicals known as tars. If I begin to experience respiratory problems when using marijuana, I will stop it and support and report my symptoms to a physician.
8. The risks, benefits, and drug interactions of marijuana are not fully understood. If I am taking medication or undergoing treatment for any medical condition, I understand that I should consult with my treating physician before using marijuana and that I should not discontinue any medication or treatment previously prescribed unless advised to do so by the treating physician.
9. Individuals may develop a tolerance to and/or dependence on marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana I should contact my medical provider.
10. Signs of withdrawal can include feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.
11. Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms, or legs, anxiety attacks, and incapacitation. If I experience the symptoms, I agree to contact my medical provider immediately or go to the nearest emergency room.
12. If my medical provider subsequently learned that the information, I have furnished is false or misleading, the recommendation for marijuana may no longer be valid. I agreed to promptly meet with my medical provider and or provide additional information in the event of any inaccuracies or misstatements in the information I have provided.
13. I have had the opportunity to discuss these matters with my medical provider, and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge that my medical provider has informed me of the nature of a recommended treatment including but not limited to, any recommendation regarding medical marijuana.
14. My medical provider also informed me of the risks, complications, and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that my medical provider informed me of any alternatives to the recommended treatment including the alternative of no treatment and the risks and benefits.
15. When under the influence and or in possession of cannabis in public a copy of your recommendation should be on your person at all times.
16. In order to stay in compliance with the California state medical board regulations it is required that you return to your recommending position for a review of your medical condition and an update of your recommendation every 12 months an outdated recommendation may place the doctors medical license in jeopardy with the medical board and the patient is at risk of being ticketed and arrested.
17. Patients giving any dishonest or untruthful information will be discharged.

We reserve the right to deny access to the Platform or the Service to anyone who violates these Terms or who, in our sole judgment, infringes on the rights of others.

1. . Services Provided

You understand and agree that the Platform (zazaMD, inc. dba ZazaMD is intended to facilitate the following services (the “Services”): (a) the development and gathering of health care records and information with retention of the same for use in medical provider encounters and communications; (b) administrative support in connection with scheduling and payment for Health Care Services; and (c) telecommunications and technology support for using the Platform as a means of direct access to medical providers provided by affiliated professional entities for communication, consultations and assessments by such medical providers.

You understand that the Platform gathers unique information from you to enable an affiliated medical provider through the Health Care Services to determine the suitability of using medical cannabis by such individuals for therapeutic purposes, diagnosis and treatment of patients over the Internet, including applicable health information (such as your past and present health conditions, and medications), diagnostic tests, as applicable, and personal information (such as your name, location and demographic information) (collectively, “Your Information”). You further understand and agree that after reviewing Your Information, the medical provider, in his or her independent professional judgment, will determine whether to approve your request for medical marijuana identification card (an “MMIC”), or, alternatively, recommend that you consult with alternative clinical resources (the “Health Care Services”).

You give us consent to send and disclose to the affiliated professional entities and their medical providers all Your Information so that you may receive Health Care Services. You also consent to allow affiliated professional entities and their medical providers to contact your primary care provider/physician to obtain further medical information to complete the request.

All medical providers who deliver Health Care Services through the Platform are: (i) independent professionals contracted or employed with affiliated professional entities that coordinate with zazaMD, inc., and (ii) solely responsible for such Health Care Services provided to you. zazaMD, inc does not provide any Health Care Services through the Platform and is not licensed to practice medicine. zazaMD, inc does not control or interfere with the provision of Health Care Services by the medical providers and affiliated professional entities, each of whom is independent and solely responsible for the Health Care Services provided to you. Therefore, you understand and agree that zazaMD, inc is not responsible for Health Care Services, or your use of any Health Care Services, provided by a medical provider or affiliated professional entity, including any personal injury or property damage.

1. Payment for Consultation

The flat fee for a remote consultation with a Healthcare Provider (the “Service Fee”) is $149.00, and is fully earned and payable upon the initial registration of the patient with the Platform or, subsequently, upon any request by the patient for a follow-up consultation (such as in the case of a required renewal of a recommendation for the use of medical marijuana (the “Recommendation”) or assistance of the Healthcare Provider in obtaining or renewing a Medical Marijuana Identification Card (an “MMIC”)). The Service Fee covers zazaMD, inc service fee and the Healthcare Provider’s service fee. Once you pay the Service Fee to us, we will transfer to the Healthcare Provider the amount of the Healthcare Provider’s portion of the Service Fee, as determined in our agreement with the Healthcare Provider. The Service Provider will not charge you any additional fees for the consultation. We expect that the Service Fee will cover a consultation with the Healthcare Provider lasting 5 to 10 minutes. If your Healthcare Provider decides that your condition requires more time or further healthcare services, he or she will schedule a follow-up consultation directly with you, or advise you of the further required steps. The Service Fee is payable whether or not the consultation results in the issuing of the Recommendation or of the MMIC.

1. Informed Consent to Telemedicine Services

Before you can use the Service, you must read and electronically sign the “Consent to being evaluated and treated through Telemedicine based services/consult.” provided elsewhere on this Site/App.

1. Summary Notice of HIPAA Privacy Practices

zazaMD, inc arranges for the provision of all Healthcare Provider services you may receive through the Platform. These Healthcare Providers are independent practitioners who advise, diagnose, and prescribe at their own discretion subject to their individual state regulations. zazaMD, inc does not directly provide or arrange for care, nor does it knowingly maintain any medical information about you for purposes of providing or facilitating care.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY zazaMD, inc AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by zazaMD, inc in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the Patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

zazaMD, inc has prepared this “Summary Notice of HIPAA Privacy Practices” to explain how it is required to maintain the privacy of your health information and how it may use and disclose your health information.

zazaMD, inc will collect directly from you some personal information (such as your full name, email address, mobile phone number, and address) and personal health information, including information about your diagnosis, previous treatments, general health, health insurance and information, if any, which you have stored in using a web-based services (such as Apple HealthKit or MyChart), to the extent you choose to synch or link that data with our services. In connection with your treatment or intended treatment, we may also collect (directly or through your Healthcare Providers) medical records from your past, current, and future health care providers, including information, if any, stored in third-party secure online accounts (such as MyChart). This may include information about your diagnosis, previous treatments, general health, laboratory and pathology test results and reports, social histories, any family history of illness, and records about phone calls and emails related to your illness. By using our Service, you hereby consent to our accessing and storing such personal and health information.

zazaMD, inc may use and disclose your medical records for each of the following purposes: treatment, payment, and health care operations.

• TREATMENT means providing, coordinating, or managing health care and related services by one or more Healthcare Providers
• PAYMENT means such activities as obtaining payment or reimbursement for services, billing or collection activities and utilization review.
• HEALTH CARE OPERATIONS include managing your Electronic Medical Record to facilitate diagnostic medical consultations with participating physicians, as well as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer service.

zazaMD, inc may also create and use or distribute de-identified health information (that is, your and other patients’ health information from a medical record that has been stripped of all data that can be used to identify a particular patient), for the purposes of zazaMD, inc’s business development (such as sharing such de-identified health information with third-party vendors and service providers that help us with specialized services, including billing, payment processing, customer service, email deployment, business analytics, marketing (including but not limited to advertising, attribution, deep-linking, direct-mail, mobile marketing, optimization and retargeting), research, analysis of data to improve the Service, performance monitoring, hosting, and data processing). These third-party vendors and service providers may not use your information for purposes other than those related to the services they are providing to us.

zazaMD, inc may contact you to provide information about our services or other health-related services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and zazaMD, inc is required to honor and abide by that written request, except to the extent that it has already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by contacting us via the contact us form page.

• You have the right to ask for restrictions on the ways zazaMD, inc uses and discloses your health information for treatment, payment and health care operations. You may also request that zazaMD, inc limit its disclosures to persons assisting your care. zazaMD, inc will consider your request, but is not required to accept it.
• You have the right to request that you receive communications containing your protected health information from zazaMD, inc by alternative means or at alternative locations. For example, you may ask that zazaMD, inc only contact you at home or by mail.