This Concierge service is to provide effective medication therapy for personal use only. Please seek medical attention with your own personal health care provider or visit any urgent care/Emergency Room should any urgent medical issues arise. We do not provide medical advice or establish medical service with the issued individual.

To the best of my knowledge, the questions of this form have been answered accurately. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor of any changes in my medical status. I also authorize the health care staff to perform the necessary services I may need.