Patient Intake

Patient Name: Alexis Audelo

I understand that: I am a legal medical marijuana patient and have the right to obtain and
use marijuana for medicinal purposes whereby medical use has been deemed appropriate
and has been recommended and/or approved by a physician licensed by the California
Medical Board or the California Osteopathic Board, who has determined that my health
(i.e., medical problem) would benefit from the use of medical marijuana in the treatment of
my medical problems, which I represented in the medical record prior to being evaluated
by my doctor whose name and info is affixed on the recommendation I am providing as
proof and for my file;

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I understand that: I am a qualified medical marijuana patient who is entitled to the
protections provided by the California Health and Safety Code sections 11362.5 and
11262.7 as well as by Senate Bill 420 and Prop 215;

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I understand that: The True and Correct copy of my most current physician's
recommendations and or approval of the use of medical marijuana is attached to this
agreement;

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I understand that: As a qualified medical marijuana patient and in accordance with the
Compassionate Use Act and the Medical Marijuana Program Act, I intend to associate with
the members of the medical marijuana collective, being hereby formed, in part, through
this agreement, in order to collectively cultivate medical marijuana for medicinal purposes
pursuant to the Medical Marijuana Program Act, which includes in part, California Health
and Safety Code 11362.775 and section 1(b)(3) of the unmodified portion of the Medical
Marijuana Program Act, which was enacted by the people of the State of California, in part,
in order to promote uniform and consistent application of the Compassionate Use Act
among the counties within this state, and to enhance the access of patients and caregivers
to medical marijuana through collective, cooperative cultivation projects;

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I understand that: As a member of this medical marijuana collective/dispensary, I
understand and agree that each and every member of this collective will contribute labor,
funds, supplies, services and or materials towards the cultivation and or procurement of
marijuana solely for medicinal purposes;

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I understand that: The collective may also provide a means for facilitating and or
coordinating transactions between members, while excluding all non-members from any
exchanges, reimbursements, provisions, remunerations or any other transactions that
involve medical marijuana;

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I understand that: None of the members of this collective shall profit from the sale or
distribution of medical marijuana and that all donations provided by patients will be used
to operate this collective in accordance with all State of California laws;

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I understand that: Medical marijuana collectives should acquire medical marijuana only
from their constituent members (i.e., patients) because only marijuana grown by a qualified
patients (with a valid and current recommendation issued by a California Licensed MD or
DO) or his or her primary caregiver may lawfully be transported by, or distributed to, other
members of a collective or cooperative (11362.765, 11362.772);

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I understand that: The collective may allocate medical marijuana to other members of the
group, and that nothing allows marijuana to be distributed or allocated outside the
collective and its lawful members (i.e., patients);

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I understand that: Marijuana grown at a collective for medical purposes may be:<br/> a.
Provided for FREE to qualified patients and primary caregivers who are members of the
collective or cooperative;<br/> b. Provided in exchange for services rendered to the entity;
<br/> c. Allocated based on fees that are reasonable, calculated to cover overhead costs
and operating expenses or;<br/> d. Any combinations of the above;<br/>

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I understand that: In accordance with the Medical Marijuana Program Act, the
Compassionate Use Act, and the 208 California Attorney General Guidelines for the
Security and Non Diversion of Medical Marijuana Grown for Medical Use this collective is
formed in accordance with California health and Safety Code 11362.775, as well as under
any and all California Health and Safety Code 11362.775 provides as follows:<br/> a. I
understand that: Qualified patients, persons with valid California Identification Card/CDL,
and the designated primary caregivers of qualified patients and persons with California
Identification Cards, who associate within the State of California in order to collectively or
cooperatively cultivate marijuana for medical purposes, shall not solely on the basis of the
fact be subject to State Criminal Sanctions under Sections: 11357, 11358, 11359, 11360,
11366, 11366.5, 115570 (H&S 11362.775);

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I understand that: According to the State of California Guidelines codified within the
Medical Marijuana Program and H & S Code 11362.77:<br/> a. A qualified patient or
primary caregiver may possess no more than 8 ounces (i.e., Eight Ounces) of dried medical
marijuana per qualified patient;<br/> b. Additionally, a qualified patient or primary
caregiver may also maintain no more than 6 mature plants (i.e., Six Mature Plans) or 12
immature plans (i.e., Twelve Immature Plans) of medical marijuana per qualified patient;
<br/> c. If a qualified patient or primary caregiver has a physician's recommendation that
specifically indicates medical marijuana quantities that are greater than those described
above, then the qualified patient and or primary caregiver may possess the amount of
medical marijuana which is consistent with the quantities indicated by the California
Licensed Physician;<br/> d. Only the dried mature possessed flowers of female cannabis
plant(s) or the plan conversion shall be considered when determining the allowable
quantities of medical marijuana under this section;<br/>

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I understand that: STIIIZY Union Square collectively cultivates medical marijuana for all
members/patients. STIIIZY Union Square, agrees to possess and or cultivate enough
medical marijuana to meet the aggregate of the needs of all qualified medical marijuana
patients/members;

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I understand that: I agree NOT to divert, furnish, sell, distribute and or give any medical
marijuana to any persons who are NOT qualified patients and members of this collective
(i.e., STIIIZY Union Square);

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I understand that: When requested of me by the collective, I agree to provide any services,
labor and or resources needed to maintain this collective, of which I am legally and
physically able to provide;

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I understand that: As a qualified medical marijuana patient whose rights are protected by
California Law, Health and Safety Code 11362.5 and 11362.7, et seq., in conjunction with
California Senate Bill 420 and Proposition 215, you are required to read and agree to the
following statements to become a member of STIIIZY Union Square Please understand that
this is for your own protection as well as ours.

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I understand that I hereby declare that I am a qualified medical marijuana patients under
California Health and Safety Code 11362.5 and 11362.7 et seq., and that my doctor has
evaluated my medical problems and subsequently recommended and approved my use of
medical marijuana for relief from my medical problems;
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I understand that as per California Safety Code 11362.51, as a legal medical marijuana
patient I can legally use and possess and cultivate cannabis for medical purposes in
accordance with the terms stated above in this agreement;

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I understand that I am allowed to do so through safe and affordable access such as the
type provided by STIIIZY Union Square, therefore, I designate STIIIZY Union Square as my
primary care provider for this purpose. In doing so, I agree to sign and follow any and all
STIIIZY Union Square, rules and regulations regarding the services provided by this
collective;

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I understand that I hereby declare under penalty of perjury laws of the State of California
that I am at least 18 years old and am a legal medical marijuana patient who was evaluated
by a California licensed medical doctor who recommended and approved my use of
medical marijuana in accordance with California State Laws and that I have been diagnosed
for a serious illness(s) for which cannabis provides substantial relief;

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I understand that a LEGAL medical marijuana patient means that I have a current medical
marijuana recommendation issued by a California licensed physician and that the medical
license of my physician is also renewed and current;

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I understand that If my recommendation is revoked or expired and or my doctors State of
California medical license is suspended, revoked or expired, that I am no longer a legal
medical marijuana patient and will have to provide a replacement medical marijuana
recommendation issued by a California license physician whose license is also RENEWED
and CURRENT;

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I understand that I hereby verify that I am a California resident and my personal medical
marijuana will not be taken out of the State of California and I further verify and agree that
the medical marijuana that I obtain will NOT be shared, sold, bartered, traded, exchanged
and or delivered/used for any other purposes other than personal use;

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I understand that I hereby declare that I understand the my contributions to STIIIZY Union
Square for and through prescribed medicinal products I may require from STIIIZY Union
Square are used to ensure the continued operation of STIIIZY Union Square, and that any
set transaction in no way constituted any commercial promotion or sale of any item;

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I understand that as a member of STIIIZY Union Square, I hereby agree, appoint and
designate STIIIZY Union Square, and their representatives as my true and correct lawful
agents for the limited purpose of assisting me in obtaining medical marijuana legal
recommended by my California Licensed physician whose name and info appears on my
current and valid recommendation;

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I understand that I hereby authorize STIIIZY Union Square to use the medical and physician
information that I have provided to verify the validity and status of my medical
recommendation from time to time. I understand that I may revoke this authorization in
writing any time, which will cause my membership status to be suspended until further
notice. I understand that all of the information that I am providing herein is protected by
HIPAA Rules and Regulations as well as Patient Privacy Laws;

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I understand that this means that STIIIZY Union Square, will be required to purchase,
possess, transport and distribute my medication to me as recommended by my California
licensed physician and I grant STIIIZY Union Square, the limited authority to do so;

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I understand that I further authorize STIIIZY Union Square to share their caregiver status of
my person in order to enter into contracts to obtain and or allow growth and preparation
of my medication and edibles containing medical marijuana;

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I understand that as a member,STIIIZY Union Square, has other members with similar
membership agreements. I hereby authorize STIIIZY Union Square, to jointly possess the
medical marijuana described under this agreement jointly with other members under
similar membership agreements. I agree that the medical marijuana possessed by any time
is the collective property of every patient who is also under this membership agreement
and under the care of STIIIZY Union Square;

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I understand that I agree to always maintain a VALID/CURRENT PHYSICIANS
RECOMMENDATION and to provide STIIIZY Union Square, with the most current
recommendation that I have been issued by my physician;

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I understand that I agree and understand that if my recommendation is expired, void,
revoked, etc., you will be denied access to obtain medication from STIIIZY Union Square,
until such that where I have resolved and provided a valid and current recommendation to
STIIIZY Union Square;

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I understand that I agree to provide STIIIZY Union Square, with accurate and current
personal contact info and further agree to immediately provide and update and changes
made to my medical condition(s), address, contact phone number, name, recommendation
status, physician contact info and license status, etc., upon any changes that occur from
those representations of contact information made in this agreement;

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I understand that I understand that this agreement is valid only during the time that I
maintain an ACTIVE and CURRENT medical marijuana recommendation and agree to
provide the most current recommendation to reflect the fact that I am a legal medical
marijuana patient.

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I understand that any member of law enforcement who is a bona fide patient must disclose
the fact that he/she is a member of law enforcement. Otherwise, by signing these terms
and conditions, I promise, state, and affirm, under penalty of perjury under the laws of the
State of California, that I am not a member of, affiliated with, nor employed by any law
enforcement department, entity, or agency.

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Notice at Collection: STIIIZY Inc. and its affiliate entities (collectively, “STIIIZY”, “we”, “our” or
“us”) are collecting your personal information and sensitive personal information to support
its business operations as further detailed in our Privacy Policy, which contains information
about the categories of personal information and sensitive personal information collected,
the purposes that it is collected, whether we sell or share such information, and our
retention practices. In addition to the purposes identified in our Privacy Policy, we may also
use information collected to comply with applicable laws, respond to law enforcement
requests, and to exercise or defend the legal rights of STIIIZY and its employees,
customers, contractors, and others. Additional information about our practices is available
in our Privacy Policy. If you have any questions about this Notice, would like to request
access to your account information, or need to access it in an alternate format due to a
disability, please contact [email protected] or [email protected]. SMS/MMS
Acknowledgement: By signing below, I agree to receive automated SMS/MMs messages to
the phone number I provided. I acknowledge that consent to receive SMS/MMS messages is
not required for purchase. At any time, I may opt-out from receiving messages by texting
STOP. I may also text HELP for any questions I may have regarding the personal
information associated with my account. Not all carriers are covered. Message and data
rates may apply. By signing below, I understand that my information will be used as
described in this Notice and Acknowledgement and as further identified in our Privacy
Policy.

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