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ALTERNATIVE SUPPLEMENT ASSISTANCE
This form is to assist families dealing with a serious medical diagnosis. 
Any forms not filled out by the child's or guardian will not be approved. 
Please expect to update Rylie's Smile Foundation as to the medical condition of your child monthly.
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DISCLAIMER
By applying, you, the guardian, are agreeing to utilize the supplement agreed upon from Rylie's Smile Foundation. Guardians agree to apply information supplied to them through consultations from Rylie's Smile Foundation.To continue receiving supplements the guardian agrees to update their foundation consultant through a secure Vcita account at least once every three to five weeks so that current information concerning the child's well being can be recorded and/or supplements can be individualized. 

The information shared is not intended to be used as a substitute for the independent judgement of a physician. Rylie's Smile Foundation is under constant development and striving toward advancements in research. We reserve the right to use collected intellectual property for the advancement of understanding the role of medical cannabis in improving serious diseases and ailments that affect quality of life. We thank you for being a part of this mission.
GUARDIAN INFORMATION
Guardian Name *
Email *
Address *
Cell Phone Number *
Our family or my child currently receives:
CHILD'S INFORMATION
Child's Name *
Does the child reside with Guardian? If not, who does the patient reside with? *
Child's Date of Birth *
MM
/
DD
/
YYYY
Diagnosis *
Date of Diagnosis *
MM
/
DD
/
YYYY
Treating Hospitals *
Attending Medical Doctors
What symptoms have they experienced from the diagnosis? *
How often does your child's health negatively affect your child's quality of life? *
How often are they receiving medical treatments? *
Medical History *
Required
Weight *
Height *
What medication and supplements are currently being taken? *
Any known allergies? *
What causes your allergic reactions?
Other illnesses not related to diagnosis:
Any surgeries in the past 5 years?
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Previous surgical history
Type of diet
Has Cannabis been used before and what has been used? Please include brand name & mg value if possible. *
If you are re-applying for assistance, please tell us how you have been using cannabis and what improvements it is making.
Reason for request of supplement assistance
Consent

As my child's legal guardian I agree to share medical information with Rylie's Smile Foundation. Rylie's Smile Foundation will not share information outside of it's organization without written permission from the child's guardian. 

I understand that the medical record release pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health  care provider or health plan covered by federal privacy regulations, the information could be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical information and/or records. 

The guardians typed name & date below serves as an electronic signature. 
Electronic Signature *
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