I, the undersigned, confirm that I have read and understand the following:

1. Cannabis is a Schedule 1 Controlled Substance. According to Federal law, it is unlawful to board a plane, cross state lines, or be on any federal land while in possession of cannabis products.
2. Under Pennsylvania law, it is unlawful to transfer, divert, or allow the use of, cannabis to anyone else, even another medical cannabis patient.
3. I understand that while my status as a patient is protected under HIPAA privacy protections, medical cannabis patients are not necessarily protected from being terminated by employers with zero drug tolerance policies if they are discovered to be using cannabis.
4. I understand that a record will be made of my purchases at Keystone Shops Dispensary ("Dispensary") and this data will be shared with State regulatory bodies.
5. I understand that I am subject to camera surveillance and recording while on the Dispensary premises.
6. I acknowledge Keystone Shops may call me (and leave a voicemail if necessary) for non-promotional purposes only.
7. I understand that using medical marijuana will impair my ability to drive a motor vehicle or operate machinery and that it is illegal to drive under the influence of medical marijuana.

Patient hereby agrees to indemnify and hold harmless the Dispensary from and against all claims, demands, damages, costs, injuries, or expenses arising out of or in any way connected with the use or misuse of medical marijuana purchased of medical marijuana.

8. Consent*
   I have read and agree to the above.
9. Signature*