By affixing your signature below, you, as the Medical Director of the practice, grant authorization to the above-named clinic contact to act as your agent for the purpose of providing prescription information for your patients. This authorization allows the clinic contact to relay information regarding medications you deem appropriate for dispensing.
Please note that you remain solely responsible for all prescription orders generated through this authorization. You are held liable for any future issues arising from such medications provided to your patients.
Should you wish to revoke this authorization for any reason, it is your responsibility to promptly notify the pharmacy in writing of the agent's withdrawal of authorized access.