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Consent To Ship
Patient Acknowledgement / Signature Required Below
Consent To Ship
Clinic Name
*
Clinic Address
*
Clinic Address
Clinic Address
Clinic Address
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Patient Name
*
Patient Name
First Name
First Name
Last Name
Last Name
Patient DOB (MM/DD/YYYY)
*
Patient Phone
*
Patient Email
*
Clinic Contact Name
*
Clinic Contact Name
First Name
First Name
Last Name
Last Name
Clinic Contact Phone
*
Clinic Contact Email
*
Right to Choose Pharmacy
By signing this form, I select Curant Health as my pharmacy. I understand that I have the right to choose the pharmacy from which I will receive medications and am not obligated to use Curant Health as my pharmacy. I also understand that I may discontinue using Curant Health at any time.
Release of Information & Consent to Ship Medications
By signing this form, I authorize Curant Health to (1) text me regarding medication updates and important information (2) contact my prescribing provider(s) to obtain new medication orders, (3) contact my current pharmacy to transfer existing prescriptions, if applicable, (4) permit Curant Health to ship medications to my requested Delivery Address.
Delivery Address (Choose One)
*
The address provided with my prescription
Deliver to the clinic marked above
Medication Packaging (Choose One)
*
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Medication Adherence Packaging
Medication Delivery
*
By checking this box, I understand that Curant Health will ship medications to the Delivery Address provided upon receipt of my initial prescription(s).
I authorize Curant Health to ship medications to the provided address for (choose one option):
*
(Select)
1 Month
3 Months
6 Months
Please Choose One Option
*
Signature Required for Medication Delivery
No Signature Required for Medication Delivery
Please Choose One Option
*
(Select)
Signed by Patient
Signed by Patient Caregiver or Authorized Clinical Staff
Authorized Signature
*
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Date
*
Additional Details (Use this field to provide additional information or preferences)
If signed by someone other than patient, please complete:
Name
Relationship/Role
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phone
866-460-8040
Headquarters
200 Technology Ct., Suite B
Smyrna, GA 30082
E-mail
customerservice
@curanthealth.com
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