I acknowledge that I am being evaluated for a physician's recommendation for certification of medical marijuana.  The physician's fee for certification is $149.95 which must be paid once application is submitted. This fee is separate from any state fees or purchase of medical marijuana.  I have not misrepresented my medical condition in order to obtain this recommendation and will abide by the consent form.  If Dr. Bojewski subsequently finds that any information I have furnished is false or misleading, the recommendation for medical marijuana may no longer be valid. I will keep my medical marijuana card in my possession at all times.