I,

hereby authorize

to pick up my prescription on my behalf. This authorization is valid for the following prescription:

I understanding signing this letter, I am granting persmission to authorized person to receive my prescribed medication from High Hopes at the Drinkers’ Lounge location.

This letter of authorization is valid for:

From start date:

After this time, a new authorization letter will be required for any future third-party prescription pick-ups.

Authorized person will provide a valid government-issued photo ID at the time of pick-up for verification purposes.