That the purpose of my consulting Integro Medical Clinics Ltd is to have my medical condition assessed by appropriate specialists to see whether or not it is appropriate to recommend the use of cannabis-based medical products (CBMPs).

The fee that I have paid is for an over-all assessment, and not specifically for the prescription or recommendation of cannabis based medical products (CBMP’s). I understand that CBMP’s might not be recommended by Integro Medical Clinics Ltd in my case.

That Integro Medical Clinics Ltd is bound by national guidelines to recommend conventional investigations or treatments appropriate for my condition, where appropriate, before considering the prescription of medical cannabis preparations.

If Integro Medical Clinics Ltd does recommend that it is appropriate to prescribe CBMP’s for me, it will pass on the recommended prescription to its pharmacy team form for me, if that is what I wish. I will be responsible for the cost of those medications.

Cannabis based medical products (CBMP’s) are different from most prescribed medicines. They are not licensed medical products, and do not have a marketing authorisation. They have not been subjected to the same rigorous safety, quality and efficacy standards that are in place for licensed medications. I understand that, at the present time, there is less medical experience generally with their use than with licensed medications. The producers of such CBMP’s are not subject to the same responsibilities as those who have marketing authorisations for authorised medical products.

It is my duty to tell Integro Medical Clinics Ltd about my medical condition and general health completely and truthfully. Failure to do so may result in reduced safety for myself, and Integro Medical Clinics Ltd may decline to carry on treating me.

I must tell Integro Medical Clinics Ltd if I am pregnant, or intend to become pregnant, or am liable to become pregnant, or alternatively to father a child while using cannabis-based products, or soon after. I am aware that use of cannabis-based products may affect my sexual health, and seriously affect the health of any children conceived or gestated (carried) or breast-fed, when CBMP’s are used.

I have read and understood the leaflet “Cannabis based medical products”.

That CBMP’s may have adverse and unwanted medical side effects. More information is given on form“Cannabis based medical products”.

These side effects may include dizziness, sedation, impaired judgement and soon, especially when commencing treatment or changing doses or preparations. This may seriously harm my ability to carry out many activities safely. Such activities include driving, operating machinery, cooking and using knives, caring for children, making important and professional decisions. Serious harm may occur as a result of carrying out such activities while adversely affected by using CBMP’s.

That care must be taken if combining the use of CBMP’s with other prescription medications, over the counter medications, herbal and illegal medications, and others. More information is given “Cannabis based medical products”.

That alcohol (ethanol) may interact with CBMP’s, and increase side effects such as dizziness , sedation, impaired judgement and so on. Document “Cannabis based medical products” contains more information about this. It is advisable not to take alcohol at all when using CBMP’s.

That if I do drive whilst using CBMP’s, I do so under my own responsibility. I should inform my motor insurers and DVLA "where required by law or insurers so to do", and carry a copy of my CBMP prescription with me in case I am stopped by the police.

That Integro Medical Clinics Ltd may approach my general medical practitioner (GP) to request information about my over-all medical condition, the opinions of specialists and others I have consulted about my current medical problem, my physical and psychological history, and seek results of tests and investigations related to my current medical problem and health in general.

That my case will be considered and discussed by different members of Integro Medical Clinics Ltd’s professional team, and that medical Cannabis products will not be prescribed without the agreement of that team.

That Integro Medical Clinics Ltd provide my GP and other clinicians involved in my care with information regarding my case.

That Integro Medical Clinics Ltd store my personal and clinical data electronically , and use electronic means to transmit such data confidentially to me, my GP, the pharmacy, and other parties involved in my care.

I understand that Integro Medical Clinics Ltd may take photographs or video and/or audio recordings of me while I am in the clinic to help serve as a record of my medical condition, and for audit purposes. These photographs or recordings may be stored confidentially as part of my medical record in paper or digital form. I am entitled to refuse to have such photographs or recordings made. If Integro Medical Clinics Ltd wish to use my photographs or recordings for any other purpose, such as research or teaching, they must ask for my permission first, and I am entitled to refuse to give my permission

I have read and understood the Information leaflets

I consent to receive communications from Integro Medical Clinics Ltd.

I give consent for Integro Medical Clinics to release my contact details and prescription details to IPS and Vertical Pharma Resources or alternative dispensary in order to contact me about my prescription to arrange delivery of my prescribed medication. I will endeavour to be at the address provided on the prescription to receive my Controlled Drug in person, which will be delivered by a courier on behalf of Vertical Pharma Resources Pharmacy. (These delivery option may be different if you choose to use an alternative dispensary)