New Patient FormFull Name:*Date of Birth: Month Day YearTel:*Address:Primary Doctor:Tel:Other Doctor:Tel:Current Pharmacy:Tel:NOTICE OF CONCENT FOR PHARMACY DELIVERY SERVICEI understand that the pharmacist on duty in his/ her professional opinion may deny delivery of my medication and instead require me to pick them up in person.I understand that I am responsible for costs of my prescription and payment due upon delivery unless otherwise stated by pharmacist in charge. I also acknowledge that the delivery driver maybe able to make limited change, cannot accept credit card payments , but may accept personal checks.I understand that if I amnot present upon delivery of my medications, the driver will wait no longer than Five (5) minutes before leaving, at which point a delivery maybe reattempted after speaking to a pharmacy staff member to confirm time and any special instructions.I understand that if I am unable to personally take my delivery, I will inform the pharmacy of whom may accept it on my behalf, as well as any other special instructions that will ensure a safe delivery.I understand that my medications may not be returned to the pharmacy unless a prescription was filled incorrectly in accordance with New Jersey State Law.I understand that deliveries are not guaranteed. If there are any issues with delivery, I will be notified by the pharmacy as soon as possible. New prescriptions will require me to contact the pharmacy in order to arrange pick up and delivery.I understand that by signing below I give consent to Optimal Pharmacy inc, my signature authorization for deliveries in the year 2020.SignatureDate MM slash DD slash YYYY CAPTCHA
