Pharmacy Customer Affidavit

Pharmacy Customer Affidavit
Legal Business Name*
Legal Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Pharmacist In Charge*

First NameLast Name
Email Address*
example@example.com
This is to affirm that the above-named pharmacy and the pharmacist and pharmacy technicians employed by the pharmacy understand the obligation to exercise
"corresponding responsibility" when dispensing prescriptions for controlled substances. Specifically, the pharmacy represents that it will only dispense prescriptions for controlled substances in situations where the prescriptions were written for a legitimate
medical purpose by a practitioner acting within the scope of their professional practice. The pharmacy further represents that it is aware of common "red flags" associated with prescriptions for controlled substances, that the pharmacy has policies and procedures for
detecting and resolving red flags, and that pharmacist have unfettered authority to refuse to fill any controlled substance prescription, if the pharmacist cannot resolve a red flag or otherwise believes that the prescription is not legitimate. This the Date*
Signature*

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Name*

First NameLast Name
Title*
Math Challenge*
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