Authorization To Pick Up Prescription

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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