Becoming Orgasmic Enrollment Form

SECTION 1 — PARTICIPANT INFORMATION

phone country Legal

Legal name

Preferred name

Date of birth

Email address

Mobile phone

City, state/province, country

Time zone

Emergency contact name and relationship to participant

Emergency contact phone

Legal eligibility – please select one:

I confirm that I am of legal age and legally eligible to possess and use cannabis in the jurisdiction where I will participate in this program.
I am not yet able to confirm my legal eligibility. I understand that I may not participate in cannabis- related program activities until legal eligibility is confirmed.

SECTION 2 — PROGRAM AND MEDICAL CARE

Becoming Orgasmic with Medical Cannabis is a 12-week educational and supportive sexual-wellness program that includes eight private Zoom sessions with Dr. Mulvehill and three private Zoom sessions with Dr. Genester Wilson-King, individualized education, practices and guidance based on each participant’s needs and progress, ongoing WhatsApp support, and a complimentary copy of Dr. Mulvehill’s Cannabis and Climax Journal to track cannabis use, sexual response, and orgasmic learning throughout the program.

Participants complete a Program Intake Form for Dr. Mulvehill to review, which provides an overview of their orgasmic and sexual-health history, previous approaches, current concerns, and goals for the program. Participants also complete the Female Sexual Function Index (FSFI) at baseline and every 30 days to track changes in sexual function and progress during the program.
The medical-cannabis component requires a separate medical assessment with Dr. Genester Wilson-King. She determines medical eligibility and provides guidance regarding cannabis dosing, product selection, medication interactions, and adverse effects within her medical role in the program.

Consent

I consent to Dr. Mulvehill and Dr. Wilson-King communicating with each other and sharing information relevant to my participation, progress, and safety, including information from my Program Intake Form, FSFI assessments, medical assessment, cannabis plan, and program progress, for the purpose of coordinating my participation in the program.

SECTION 3 — PARTICIPATION

Participation in exercises and practices is voluntary. Participants may decline, modify, pause, or discontinue an exercise at any time.

Individual responses vary, and no specific outcome, including orgasm or improvement in sexual function or pleasure, is guaranteed.

Changes to cannabis use or other medical treatment should be discussed with Dr. Wilson King or the participant’s treating healthcare professional.

SECTION 4 — CANNABIS EFFECTS

Potential physical and psychological effects
Cannabis can affect attention, coordination, judgment, mood, perception, anxiety, heart rate, and other physical or psychological responses. Individual responses may vary according to dose, product, route of administration, health history, medications, setting, and other factors.

Checkboxes

I have read and understand the potential physical and psychological effects of cannabis described above.

SECTION 5 — TUITION, REFUNDS, AND APPOINTMENTS

Please select one:

Three-payment plan: $1,000 at enrollment and two additional monthly payments of $1,000, for total tuition of $3,000

Enrollment is confirmed when the signed Enrollment and Participation Agreement and the initial tuition payment are received.

If a participant withdraws from the program, any refund will be based on the amount paid minus the value of services already provided. Each completed one-hour private session with Dr. Suzanne Mulvehill or Dr. Genester Wilson-King is valued at $250 for purposes of calculating a refund.

Scheduled appointments must be canceled or rescheduled at least 24 hours in advance. Appointments canceled or rescheduled with less than 24 hours’ notice will be considered completed for purposes of the refund calculation and valued at $250.

For example, if a participant pays the initial $1,000, completes one session with Dr. Mulvehill and one session with Dr. Wilson-King, and then decides not to continue, $500 will be refunded.

SECTION 6 — PARTICIPANT AGREEMENT

By signing below, I confirm that the information I provided is accurate to the best of my knowledge, that I have read and understand this Enrollment and Participation Agreement, and that I voluntarily agree to participate in the program.

Certification and Electronic Signature

I agree and intend my typed name below to serve as my electronic signature

By checking the box above and typing my full legal name below, I certify that the information provided in this enrollment form is accurate and that I have read and agree to the acknowledgments, terms, and consent statements contained in this form.

Electronic Signature - Type Your Full Legal Name Below

Date

What happens next?

After submitting this Enrollment and Participation Agreement and your initial tuition payment, you will receive the Program Intake Form and baseline Female Sexual Function Index (FSFI) from Dr. Suzanne Mulvehill. You will also complete a separate medical assessment with Dr. Genester Wilson-King before beginning the medical-cannabis component of the program.