customerservice@curanthealth.com
866-460-8040

Consent To Ship

Patient Acknowledgement / Signature Required Below
Consent To Ship - TLFamily

3367, 3376

TL Family Nurse Practice

 

Patient Name
Patient Name
First Name
Last Name
Clinic Contact Name
Clinic Contact Name
First Name
Last Name
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)
Medication Packaging (Choose One)
Medication Delivery
Please Choose One Option
If signed by someone other than patient, please complete:
Start Over

phone

866-460-8040

Headquarters

200 Technology Ct., Suite B
Smyrna, GA 30082

E-mail

customerservice

@curanthealth.com
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