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Name
Patient First Name
Patient Last Name
Date of Birth
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Month
-
Day
Year
Date
Social Security Number (note: if the patient is a minor, please provide the social security number of Parent/Guardian/Legal Representative)
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Passport or Driver's License# (note: if the patient is a minor, please provide a Passport or Driver’s License photo of their Guardian/Legal Representative.)
*
Photo of State-issued Personal Identification (note: a photo on file is required to ship medications; if the patient is a minor, please provide a photo of their Guardian/Legal Representative.)
*
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Name of Employer
Personal/Authorized/HIPAA Representative
Personal/Authorized/HIPAA Representative (The person, usually a family member, friend, or legal guardian, designated under state law to make health care decisions and manage your information on your behalf.)
Representative First Name
Representative Last Name
Consent and Signature
By checking the box(es) below, you confirm your consent to receive voicemail and/or SMS or secure email messages from NASH for important reminders regarding your prescription, including delivery/refill updates. You understand that SMS message and data rates may apply.
Yes, I would like to receive text messages from NASH.
Yes, I would like to receive emails from NASH.
Patient or Guardian/Legal Representative
First Name
Last Name
Relationship to Patient
Today's Date
-
Month
-
Day
Year
Date
Signature of Patient or Guardian/Legal Representative
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