COMPASSION PROGRAM

Dear Patients,

In our intention to help those in need, we have established The Compassion Program to serve patients experiencing both extreme physical and financial hardships. We provide qualifying patients with a 30% discount on all medicine and give out complimentary products.

Checklist of paperwork you will need to turn in for evaluation:

Compassion Application that is filled out completely.

Medical Diagnosis from Primary Care Physician or Specialist

Current, valid, and verifiable Dr’s recommendation for cannabis

Proof of monthly income

Photo identification/copy of your I.D. attached to packet

6. Caregiver’s information: If you are unable to pick up your medicine because of your condition and need someone to pick it up for you, they must fill out a Care-Giver Application and get a Dr’s cannabis recommendation. This is for legality purposes. Your application will not be processed if any information is missing. Once your packet is complete, turn it into the front desk. Our Compassion Director’s Mike and or Shannon will contact you to answer any questions you may have.

Please know that there may be a waiting list to get into this program. You will be notified by phone or email if you qualify. This program includes:

30% Discount on all products

Complimentary Products

Express Orders - Call (530) 303-3120

4. Or order online at - https://chucks.treez.io/onlinemenu/?customerType=ADULT

Chuck’s Wellness Center

Compassion Application

Patient Member Application Form

(PLEASE PRINT AND RETURN TO CHUCKS)

Patient Name: _____________________________________________________

(First) (Last)

Address: __________________________________________________________

(City, State, Zip Code)

Phone Number: __________________ Email:____________________________

Driver’s License #:______________________ D.O.B______________________

Doctor’s Name: ____________________________________________________

(First) (Last)

Doctor’s Phone Number: ____________________________________________

Doctor’s Website: __________________________________________________

Date of Recommendation: _________________Expiration Date:____________

Medical Diagnosis: __________________________________________________

_________________________________________________________________

How did you hear about our “Compassion Program”

_______________________________________________________________

Monthly Income $:____________________

Source of Income:____________________

Do you receive?

Cal-Works

SSI –D

TANF Cal-Fresh

Are you a veteran?

Do you receive military benefits?

Yes

Do you have Medical Coverage?

Yes

Medical Insurance Provider: _______________________________________

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION

I, ______________________________________(name), state that all information in this application is accurate and true to the best of my knowledge. I authorize Chuck’s Wellness Center and its representatives to verify this information including my medical diagnosis and my doctor’s recommendation for using cannabis with my doctors.

Patient Signature:_____________________________________________

Date:_____________________

What forms of cannabis would you like to try or are using now?

* Flower

*Tincture

* Concentrates

*RSO

* Edibles

*Capsule

*Topical

*Spray

What forms of cannabis would you like more information about?

* Flower

*Tincture

* Concentrates

*RSO

* Edibles

*Capsule

* Topical

*Spray

Do you have a treatment plan that requires specific cannabinoids? THC, CBD, CBN, CBG, THC-A, Other:______________________

Chuck’s Wellness Center

Liability and Medical Release Form

I hereby agree to release Chuck’s Wellness Center (including: its representatives, landlords, agents, volunteers, contractors, therapists, service providers and employees) from liability for any injury and/ or resulting from any cause whatsoever from any information, consultation and products provided for me. I understand that the services and products provided to me by Chuck's Wellness Center is to assist me on my own path of healing, and that there is no promise of cure. I agree to consult my doctor before reducing or stopping use of pharmaceutical medications. I understand that THC can cause negative side effects including but not limited to anxiety, sedation, increased heart rate and decreased motor skills. I understand that I should never drive under the inﬂuence of THC. I understand that cannabis can have psychoactive properties, and that the effects and dosing vary widely with everyone. I understand that should I choose to use THC I must use extreme caution and microdose to determine the effective dose and products for my own personal therapy. I do voluntarily authorize the Chuck's Wellness Centers staff, assistants and/ or designees to administer and/or obtain routine or emergency diagnostic procedures and/ or emergency medical treatment to me as deemed necessary. I agree to authorize Chuck's Wellness Center’s staff, assistants and/ or designees to verify the validity of my medical records, diagnosis, and recommendation with my doctor (if medical). I agree to authorize Chuck's Wellness Centers staff, assistants and/or designees to contact me by phone or email. I agree to indemnify and hold harmless Chuck's Wellness Center for all claims, demands, actions, rights of action and/ or judgments by or on behalf of the named person arising from or on account of said consultation, advice, procedures, products and/ or treatment rendered in good faith. This release is for all liability for personal injuries, death and property losses or damage occasioned by, or in connection with any activity, product, accommodation, or service of Chuck's Wellness Center.

By signing below, I conﬁrm that I have read, understand and agree to abide by the Liability and Medical Release Form of Chuck's Wellness Center:

Signature:_______________________________________Date:_______________________

Chuck’s Wellness Center Private Membership Compassion Guidelines

Please Read and Initial Each Guideline Below

___Medical Patient Member on Compassion Program and providers must provide a valid CA State issued photo identiﬁcation and medical recommendation from a licensed doctor for every visit to Chuck’s Wellness Center. Tax is not included in pricing.

___You must always act in a loving and respectful way to one another and the dispensary staff and our neighbors.

___Do not litter. Please dispose of trash in designated receptacles only.

___Smoking, ingesting, or consuming cannabis on this property or within THREE blocks of the dispensary is prohibited. PLEASE DO NOT SMOKE IN THE PARKING LOT.

___No loitering. Please do not bring anyone to Chuck’s Wellness Center that is under the age of 21 or a qualiﬁed patient over the age of 18, including your children.

___Please no cell phone conversations in the building. Internet use and texting is okay in the waiting areas only.

___Please keep all cannabis edibles in child resistant packaging and away from children and pets.

___Do not drive while under the inﬂuence of cannabis and do not use cannabis while driving.

___All members shall act in conformance with all California Cannabis laws and regulations and the City of Placerville’s cannabis regulations.

___Proposition 65 Warning: “Chemicals known to the State of California to cause cancer and birth defects, or other reproductive harm are present in certain cannabis products produced, stored, processed, packaged and dispensed from this facility.”

___I have read, understand, and agree to abide by the rules, noncompliance to any of the above rules is grounds for membership and Compassion program termination.

Signature:_____________________________Date:________________________________

TESTIMONIAL

Please tell us about your experience with cannabis and what you will be using it for?

____________________________________________________________

530-303-3120