Restricted Pharmacy Agreement

I am seeking healthcare services from the physicians and providers at Valley Medical and Wellness (VMW) for the treatment of my condition. I acknowledge that I intend to provide all necessary releases for healthcare and to be accurate, complete, and truthful in disclosing my history and symptoms so that VMW may safely treat me for my condition. By signing below I understand and agree to the following:

1. I give consent for VMW to share medical history with the pharmacy or pharmacies listed in this agreement so that my prescriptions may be monitored for my safety and continuity of care.

2. I understand that obtaining prescription medication(s) through false representation is a crime, and that I will be reported to local law enforcement officials for attempting to fraudulently obtain prescription medications for non-therapeutic purposes.

3. If I need to change pharmacies I will contact Valley Medical and Wellness’ clinic manager, choose a different pharmacy, and fill out a new Restricted Pharmacy Agreement with the clinic manager’s approval.

4. I agree to only use one pharmacy, except when otherwise noted below, to get my medications(s). The name of my pharmacy is:

I have read and understand what is required of me.