By booking the appointment below, I hereby voluntarily consent to all health care services ordered/provided by Schaffner Pharmacy and its associated health care practitioners for me or the patient for whom I am responsible.

I authorize the pharmacy to maintain a copy of this signed form and submit any pertinent information to local health departments, as required, and/or my primary care provider for continuity of care. I indemnify the organizing body and all persons connected with them from any and all claims that may result from my voluntary participation in the below service.

I understand that Schaffner Pharmacy will attempt to bill my medical/prescription insurance for services rendered. Copays and deductibles may apply, should insurance deny the claim I understand I may be solely financially responsible for services rendered.