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   Authorization To Pick Up Prescription

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Authorization to Pick Up Prescription

Name: _________________________________

Address: _________________________________

City, State, Zip _________________________________

Email _______________Phone ____________


I, the undersigned, hereby authorize _____________________________ to pick up the following prescription(s): ___________________________________.


This should be considered a standing authorization, without set pick-up dates or times. I and the authorized personnel understand that s/he will be required to produce a government-issued photo ID upon pick-up every time.


Signature _________________________ Date __________

Witness    _________________________ Date __________

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Formatted and ready to use with Microsoft Word, Google Docs, or any other word processor that can open the .DOC file format.


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