Patient Information & Notice of Privacy Practices

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    Yes, please list belowNo known drug allergies


    Please list all medications you are currently taking including prescription, over the counter, and herbal medications.

    Request to Dispense Prescription Medication in Non child-resistant Container and Release, Hold Harmless and Agreement to Indemnify.

    I understand that all prescription medications are required to be dispensed in a child-resistant container unless the patient or the patient’s agent authorizes the pharmacist to dispense the medication in a regular (non child-resistant) container.

    I certify that I am the patient or the patient’s authorized representative and agent and that I request that all medications, now and in the future, for the below named patient be dispensed in a non child-resistant container.

    I understand that prescription medications may be dangerous, especially to children and that a regular (non-resistant) container increases the risk that a child may get hold of the medication in the container. I understand that this may cause serious injury or even death to a child or other person getting hold of this medication.

    I hereby release the pharmacist and the pharmacy from all liability, which may be caused by the lack of a child-resistant container for any medications for the below-named patient.

    I hereby agree to hold harmless and indemnify the pharmacy and its agents and pharmacists from any loss or damage to any and all third parties including children and their relatives which may result, in whole or in part, from the lack of a child-resistant container for any medications for the below-named patient which have been dispensed in regular (non child-resistant) container as authorized and requested in this Release, Hold Harmless and Agreement to Indemnify.

    Patient Name:
    Acknowledgement of Receipt of the Notice of Privacy Practices

    By signing this form, I acknowledge the receipt of the Pharmacy's "Notice of Privacy Practices" (Notice), which contains description of the uses and disclosures of protected health information that may be made by the Pharmacy, and of my rights, and the Pharmacy's responsibilities, with respect to protected health information. I have read and understand my rights under the Notice. I also understand the Notice is subject to change and I can request a current written Notice at anytime.

    The Pharmacy is required to obtain my written authorization before using or disclosing my personal health information for purposes other than those provided for in the Notice or as otherwise permitted or required by law. I understand that I have the right to revoke this authorization in writing, except to the extent that the pharmacy has relied on it.

    My signature below signifies I have read and understand the Notice.