Authorization Form
ALL INFORMATION WILL REMAIN CONFIDENTIAL.
Please Initial:
I authorize Total Health Care Pharmacy to send me txt messages when my prescription is ready and/or reminders for when medications are due. Message and data rates may apply.
I authorize Total Health Care Pharmacy to enroll me in MED SYNC, whereby all my maintenance medications will be processed on the same day every month to save me multiple trips to the pharmacy.
I authorize Total Health Care Pharmacy to AUTOMATICALLY DELIVER my medications for me when they are ready. I understand that I do not need to be present for delivery, and the driver is authorized to leave the medication at my place of residence.
I authorize Total Health Care Pharmacy to monitor my Diabetes therapy in collaboration with other providers in the clinic.
I authorize Total Health Care Pharmacy to send me promotional messages about new programs, promotions, patient satisfaction surveys, etc. through txt message or phone call. Message and data rates may apply.
I understand that I may remove my authorization for any or all of the above items at any time and that I must notify a staff member of Total Health Care Pharmacy to remove or make changes to any of the information provided.
Please update your contact information:
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
Today's Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: