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Your Wellness and Achievements Center

Patient Authorization for Delivery of Medications

I,hereby authorize the clinic's staff on duty to act on my behalf to accept medication delivery from the clinic's dispensing nurse practitioner and deliver my medications and refill to me as prescribed by the practitioner.

I understand that delivery of such medications will be mailed to my provided address as often as ordered by the practitioner. This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing.

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 intake and practitioner's examination.

At the practitioner's discretion only, you will be provided with medications and/or services pertaining to your treatment at Your Wellness and Achievements Center.