Leafwell Authorization for Disclosure and Use of Information Last

Updated on June 1, 2025

I hereby authorize Leafwell, Inc. (“Leafwell”), Leafwell MD, P.A., Leafwell MD NJ, P.C., and affiliated medical practices (collectively, “Affiliates”) to share my personal information with licensed Illinois dispensaries (“Partners”), for the purposes described below.

Information to be Shared: I authorize Leafwell to disclose the following information collected in my interactions with Leafwell: First and Last Name; Email Address; and Medical cannabis patient status.

Recipient(s) of the Information: The information listed above may be disclosed to Partners, which are licensed medical cannabis organizations operating in compliance with applicable state law.

Purpose of Disclosure: This authorization permits Leafwell and its Affiliates to share my information with Partners so that I may receive marketing communications about cannabis-related products, services, events, or promotions. These communications may include but are not limited to promotional offers, product pricing updates, coupons, discount codes, and new service announcements.

Remuneration: I understand that Leafwell may receive direct or indirect compensation from Partners in connection with the disclosure of my information for marketing purposes.

Expiration: This authorization remains valid until I revoke it in writing, unless otherwise limited by state law.

Right to Revoke: I may revoke this authorization at any time by sending a written request to Leafwell support@leafwell.com. Revocation will not affect actions taken before receipt of the request.

Voluntary Consent: I understand that signing this authorization is voluntary, and my treatment or services from Leafwell will not be affected if I choose not to sign.

Acknowledgment: I have read and understand this authorization. I consent to the sharing of my information with Partners for marketing purposes as described above. I understand that once my information is shared, Partners are responsible for protecting it under applicable laws, including the Illinois Cannabis Regulation and Tax Act.