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APPOINTED PHARMACY CONSENT SUBOXONE (buprenorphine HCl/naloxone HCl dehydrate) sublingual tablet SUBTEXT (buprenorphine HCl) sublingual tablet I do hereby: (MD check all that apply) Patient Name (Print)

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How to fill out appointed pharmacy consent

01

Step 1: Obtain the appointed pharmacy consent form from the pharmacy or healthcare provider.

02

Step 2: Read the instructions carefully before filling out the form.

03

Step 3: Provide your personal information such as name, date of birth, and contact details.

04

Step 4: Indicate the name of the pharmacy you are appointing as your preferred pharmacy.

05

Step 5: Specify any specific medications or prescriptions that you want the appointed pharmacy to handle.

06

Step 6: Sign and date the consent form to validate your agreement.

07

Step 7: Return the completed form to the pharmacy or healthcare provider as instructed.

Who needs appointed pharmacy consent?

01

Individuals who want to designate a specific pharmacy as their primary pharmacy for managing their medications and prescriptions.

02

Patients who require specialized care or have unique medication needs that can be better addressed by a particular pharmacy.

03

People who frequently visit multiple healthcare providers and need a centralized pharmacy for medication management.

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What is appointed pharmacy consent?

Appointed pharmacy consent is a document signed by a pharmacy that allows a designated person or entity to pick up controlled substances on behalf of the pharmacy.

Who is required to file appointed pharmacy consent?

Pharmacies that dispense controlled substances are required to file appointed pharmacy consent.

How to fill out appointed pharmacy consent?

Appointed pharmacy consent can be filled out by providing the necessary information about the designated person or entity picking up controlled substances.

What is the purpose of appointed pharmacy consent?

The purpose of appointed pharmacy consent is to ensure that controlled substances are only picked up by authorized individuals or entities.

What information must be reported on appointed pharmacy consent?

Information such as the name of the designated individual or entity, their relationship to the pharmacy, and any relevant contact information must be reported on appointed pharmacy consent.

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