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TELEMEDICINE CONSULTATION
Medical Liability Waiver & Acknowledgment 

TELEMEDICINE MEDICAL CANNABIS EVALUATION

Medical Liability Waiver & Acknowledgment Simply Sweet Health, LLC d/b/a Elevated Certs

Consent to Evaluation and Treatment

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Consent to Professional Medical Evaluation

I authorize Nathaniel Arnatt, NP-C (“Practitioner”), practicing through Simply Sweet Health, LLC d/b/a Elevated Certs (“Practice”), to perform a professional medical evaluation via telemedicine or in person for the purpose of determining eligibility for a medical cannabis certification. All determinations are made using the Practitioner’s independent clinical judgment, consistent with applicable Virginia law, regulations, and professional standards. This consent is effective for 365 days unless revoked in writing.

Nature of Service; Not Insurance

This Agreement covers a professional medical evaluation and related counseling services associated with a medical cannabis certification determination. This service is not health insurance and does not provide comprehensive primary care, emergency care, hospital services, specialty care, or ongoing treatment. Patients are encouraged to maintain health insurance for services not provided under this Agreement.

Limited Scope of Evaluation

The evaluation provided under this Agreement is limited in scope to assessing whether issuance of a written medical cannabis certification is clinically appropriate under Virginia law. This evaluation does not establish the Practitioner as the Patient’s primary care provider, psychiatric provider, or substance use disorder treatment provider. The Practitioner does not assume responsibility for the ongoing diagnosis, treatment, or management of psychiatric conditions, substance use disorders, or other chronic medical conditions, which remain under the care of the Patient’s existing treating clinicians.

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Medical Cannabis Evaluation and Certification Determination

The evaluation is conducted in the course of professional practice to determine whether issuance of a written certification is appropriate. Issuance of a certification is not guaranteed and does not constitute a prescription, endorsement, or guarantee of therapeutic benefit. The Practitioner does not prescribe, dispense, dose, titrate, or manage cannabis products and does not control patient use following certification.

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Prescription Monitoring Program Review

As part of routine patient safety assessment, the Practitioner may access and review the Virginia Prescription Monitoring Program (PMP/PDMP) and other applicable prescription monitoring databases. Information obtained may be used to assess medication history, identify potential safety concerns, and inform clinical decision-making, including the decision to issue, decline, or discontinue a medical cannabis certification. Review of the PDMP does not independently impose a duty to contact, notify, or

collaborate with other prescribers unless expressly requested and authorized by the Patient in writing.

No Duty to Coordinate or Collaborate with Other Providers

The Patient acknowledges that the Practitioner is not responsible for coordinating care with, notifying, or obtaining approval from the Patient’s other healthcare providers regarding medical cannabis certification unless the Patient expressly requests such coordination and provides valid written authorization. Differences in clinical opinion among healthcare providers do not, by themselves, indicate a deviation from the applicable standard of care.

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Right to Decline or Discontinue Certification

The Practitioner retains sole discretion, exercised through independent clinical judgment, to decline to issue, renew, or continue a written certification at any time if certification is not clinically appropriate, presents patient safety concerns, or is inconsistent with applicable law or professional standards. Disagreement with clinical judgment does not entitle the Patient to certification.

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Telemedicine Consent

Telemedicine involves the delivery of healthcare services using real-time interactive audiovisual technology. Telemedicine is utilized only when clinically appropriate, and in-person evaluation may be required based on the Practitioner’s judgment. Telemedicine services are not emergency services.

Accuracy of Information and Patient Responsibility

The Patient attests that all information provided is accurate and complete. Material misrepresentation or omission may result in denial or discontinuation of certification. The Patient retains responsibility for informing other healthcare providers of participation in the medical cannabis program unless the Patient requests and authorizes coordination of care.

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Medical Cannabis Risks and Patient Acknowledgments

The Patient acknowledges the federal illegality of cannabis, potential adverse effects, impairment risks, employment and legal restrictions, potential drug interactions, and possible effects on mood or psychiatric symptoms. The Patient agrees to seek care from appropriate mental health professionals for monitoring and management of such conditions.

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No Substitution for Prescribed Medications

A medical cannabis certification is not a substitute for prescribed medications and does not advise discontinuation or alteration of any treatment without consultation with the prescribing clinician.

Scope Limitation; No Advocacy or Representation

The Practitioner’s role is limited to medical cannabis certification evaluation. The Practice does not provide legal advice, advocacy, or representation to employers, courts, regulatory agencies, or other third parties.

Governing Law and Venue

This Agreement is governed by the laws of the Commonwealth of Virginia, with exclusive venue in Orange County, Virginia.

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Entire Agreement

This Agreement constitutes the entire agreement regarding the services described herein. If any provision is determined to be unenforceable, the remaining provisions shall remain in full force and effect.

Patient Acknowledgment

By signing the Telemedicine Consultation and selecting “I agree” to the Terms and Conditions via JotForm, the Patient acknowledges and accepts the legally binding nature of electronic signatures; confirms understanding of this Agreement; acknowledges that issuance of a medical cannabis certification is discretionary and not guaranteed; and voluntarily consents to the professional medical evaluation. The Patient further understands that participation in a state medical cannabis program is voluntary, subject to evolving laws and professional standards, and that differences in clinical opinion among healthcare providers do not invalidate the Practitioner’s independent clinical judgment.

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