In accordance with GA Rule 480-16-.02(3), which reads "In order for a patient to authorize a licensed medical practicitioner to hold, administer, or deliver the patient's prescription drug at his or her office location, and the drug was previously dispensed and delivered to the practitioner's office by a pharmacy, the patient must first provide the pharmacy with written authority to conduct a delivery".
I hereby consent to allowing Integrity Compounding Pharmacy to deliver my prescription drugs to my licensed medical practitioner. This consent will apply will apply to all prescriptions dispensed by Integrity Compounding Pharmacy for me, indefinitely, unless revoked in writing at 8601 Dunwoody Place, Suite 750, Sandy Springs, GA 30350.