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Patient Authorization for Delivery of Medications
hereby authorize the clinic’s staff on duty to act on my behalf to accept medication delivery from the clinic’s dispensing physician and deliver my medications and refills to me as prescribed by my physician. I understand that delivering such medications can be picked up at the clinic or mailed to my provided address every week (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. If your state is not licensed by any of the compounding pharmacies, we are allowed to sign for the order and send it to the patient. Any orders delivered damaged or incomplete must be reported to Illinois Alternative Medicine; referred to as IAM, within 24 hours of delivery, and the pictures of damaged package/product must be sent to email@example.com. IAM is not financially responsible or liable for lost or stolen items once delivered. Once items have been scanned as delivered to the customer's address, it is up to the customer to report any missing or stolen packages to IAM within 24 hours of the delivery date. Any packages returned for an incomplete/incorrect address can be shipped again at the patient's expense. 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 physician’s examination. At the physician’s discretion only, you will be provided medications and/or services during your program at IAM. IAM requires you to have an annual consultation with our provider, and annual lab work is done. Lab work every 6 months is preferred but not required. The provider can request additional lab work at any time. No Refund Policy *IAM reserves the right to have no return and no refund policy.
Draw your signature:
I understand this is a legal representation of my signature.
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