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Medical Consent
Agreement for Controlled Substances

THIS INTAKE FORM ALLOWS YOU TO INDICATE YOUR PREFERENCE OF PRESCRIPTION DRUG PRODUCTS. UPON COMPLETING THIS FORM, ONE OF OUR LICENSED PHYSICIANS WILL REVIEW YOUR MEDICAL INTAKE AND DETERMINE WHETHER AND WHAT PRODUCTS ARE MEDICALLY APPROPRIATE FOR YOU BASED ON HIS/HER MEDICAL EVALUATION CONDUCTED VIA TELEMEDICINE. SHOULD THE PRESCRIBING PHYSICIAN HAVE ANY QUESTIONS REGARDING YOUR MEDICAL HISTORY, HE/SHE WILL CONTACT YOU THROUGH OUR PATIENT PORTAL. YOU CAN COMMUNICATE WITH YOUR PRESCRIBING PHYSICIAN AT ANY GIVEN TIME BY GOING THROUGH YOUR PATIENT PORTAL.