Legal review draft
Patient Authorization and Consent
Proposed adult-patient authorization language. The production workflow requires an approved, versioned form signed in person after identity verification.
Draft version: 2026-07-13-counsel-clinical-draft. Effective date to be assigned only after approval.
Voluntary request
I request a clinician eligibility evaluation and, if certified, administrative assistance with an Illinois adult medical-cannabis patient application. I understand that I may ask questions and may decline or withdraw this authorization before submission, subject to record-retention requirements.
No promised outcome
I understand that the clinician makes an independent certification decision and Illinois makes the application decision. No certification, approval, medical benefit, delivery method, or processing time is promised.
Information and submission authorization
After reviewing the prepared information, I authorize the approved application data and required documents to be submitted through the applicable Illinois process. I will identify corrections before signing and understand that the signed version and submission evidence are retained.
Identity verification and revocation record
The final authorization is witnessed in person after government-photo-ID verification. A later revocation request does not erase the historical authorization or actions already taken; the system records the revocation, reason, actor, and time as a new audit event.
Questions and requests
Call 773-896-0420 or email contact@peaceofmindmmj.com. Do not include medical details in ordinary email.