Request for Third-party Pickup

I,

Name(Required)

hereby authorize

Authorized Person for Pick-up

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:

Start Date(Required)

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.