I acknowledge that, in order to begin or renew the certification procedure to obtain a medical card, The Sanctuary Wellness Institute, LLC (“Company”) will process my information for the purpose of obtaining a physician appointment for clinical evaluation by a physician. I am an adult individual with authority to request the services of Company, and the services of a registered physician under the Act without the need for permission or consent from any other individual. I acknowledge that Company is not a medical practice and its members, employees or agents are not physicians; further, I acknowledge that I am not relying on the Company or its members, employees or agents to provide medical evaluation or treatment to me; further, I acknowledge that Company, in obtaining an appointment for me, relies exclusively on the published listing of approved registered physicians and is not responsible for any errors or omissions concerning such publication.
I acknowledge that, if necessary for Company to assist me with my certification or re-certification and acquisition of a medical card. I hereby voluntarily consent (under applicable law and regulations, including Health Insurance Portability and Accountability Act) to disclosure by Company of my qualifying condition (as communicated by patient to Company) under the Act only to a registered physician and, if necessary, only for the purpose of coordinating my appointment with a registered physician. I hereby release Company, its members, employees and agents from any claim related to my requests for services from Company, and any claim related to Company’s handling of my requests for services in normal course of Company’s operations, and any claim related to erroneous information contained in the publications provided by the the State pursuant to the Act, and any claim related to any act (or failure to act) of any physician alleged to constitute medical malpractice or malfeasance.
I authorize company to process fee, on behalf of physician, for certification or re-certification.