By signing this form, I authorize Athena Compounding to release my prescribed medications and/or medical supplies to the person(s) listed below. I understand that Athena Compounding may require valid identification from the authorized representative at the time of pickup. I give my permission for Athena Compounding to share and discuss my Protected Health Information (PHI)-including but not limited to medication names, directions for use, potential side effects, and counseling information-with the authorized representative(s) listed on this form, solely for the purpose of ensuring proper receipt and understanding of my prescribed therapy.

I acknowledge that this authorization complies with all applicable Georgia Board of Pharmacy regulations and HIPAA privacy requirements. I understand that this consent will remain in effect until I revoke it in writing by contacting Athena Compounding. I understand that I may revoke this authorization at any time by submitting a written request. I release Athena Compounding, its pharmacists, and employees from any and all liability arising from the release of medications and/or PHI to the authorized representative(s) named above.

I acknowledge that the medication being dispensed by Athena Compounding has been prescribed by a licensed healthcare provider specifically for the individual patient named on the prescription. I understand that although the medication may be delivered to or picked up by a clinic, medical office, or authorized healthcare provider, the medication is the sole property of the patient for whom it was prescribed. The clinic, facility, or provider may not re-dispense, resell, alter, or use this medication for any other patient or purpose other than as directed for the named individual. I understand that any misuse, diversion, or misrepresentation may be in violation of state and federal law, including Georgia Board of Pharmacy regulations and FDA 503A requirements.

I understand that I have the right to request counseling and receive prescription drug information directly from a pharmacist, either by phone or in person. If I have questions about my medications, I acknowledge that it is my responsibility to contact Athena Compounding for clarification or guidance.

Authorized Representative: Dr. Hugo Ribot

Address: 958 Joe Frank Harris Parkway SE, Suite A102, Cartersville, GA, 30120