Patient Authorization For Delivery of Medications
By checking the box you are hereby authorize the clinic’s staff on duty to act on your behalf to accept medication delivery from the clinic’s dispensing nurse practitioner and deliver the medications and refill to me as prescribed by the practitioner. You understand that delivery of such medications can be picked up at the clinic or mailed to your provided address on a weekly basis (or as often as ordered by the practitioner). This authorization will remain active for the course of your treatment at this clinic or until you revoke it in writing.
No Guarantee of Services
We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign-up process and practitioner’s examination. At the practitioner’s discretion only, you will be provided with medications and/or services during your program with Bloomble Rx.