Consent To Ship

Patient Acknowledgement / Signature Required Below

Consent To Ship - Valley AIDS 3VA

3VA

Valley AIDS

Patient Name

First Name

Last Name

Patient Date of Birth

Patient Phone

Patient Email

Clinic Location

Clinic Contact Name

First 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)

Bottles

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:

Please Choose One Option

Signature Required for Medication Delivery

No Signature Required for Medication Delivery

Authorized Signature