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I hereby declare that I will truthfully and completely disclose all information regarding my medical and behavioral health condition(s). I agree to provide supporting documents pertaining to my medical condition(s) if requested. I will provide documentation to a Semaj provider to be certified for the medical use of cannabis. I have reviewed a copy of the Notice of Privacy Practices, and accept those practices. I acknowledge that it is my sole responsibility to participate in the follow up during my 6th month of treatment.
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