Authorization to Ship Medication Form


    Authorization to Ship Medication without Signature Form
    I hereby authorize Medicine Man Compounding Pharmacy to ship my medications without anyone being present to obtain signature for delivery. I understand in doing so that I am accepting all liability for any loss or damage to my prescription(s) once it has been delivered. I also understand that in signing this release that I am foregoing my right to hold Medicine Man Compounding Pharmacy responsible for any of my protected health information that is disclosed once the delivery has been made. This authorization and release will remain in effect as long as deliveries are being made on my behalf on until I notify Medicine Man Compounding Pharmacy in writing.


    Patient Name:









    Date of Birth:







    Email:







    Patient Signature:





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