Authorization to Ship Medication
I hereby authorize Goldsmith MediCenter Pharmacy to ship my medications. I understand that this authorization does not require a recipient present to obtain signature for delivery. In signing this authorization, I am accepting all liability for any loss or damage to my prescription(s) during shipping. I am foregoing my right to hold MediCenter Pharmacy responsible for any of my protected health information that is disclosed once the delivery has been made. This authorization and release will remain in effect as long as I am a patient at MediCenter Pharmacy or I notify MediCenter Pharmacy in writing that I revoke this authorization.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Signature
*
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