This clinic, its staff and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider.
Should an approval be made for my medicinal prescription or services provided, I understand that terms and return dates will be specified. I understand that it is my responsibility to see a physician to assess the possible continuance of prescribed medicine(s) or provided service(s) beyond the terms of approval. I understand that the benefits and risks associated with the use of medicine(s) or service(s) may not be fully understood and that the use of medicine(s) or service(s) may involve risks that have not been identified.
I certify that I have carefully read all the DISCLOSURES and CONDITIONS above with full understanding and agreement.
I certify that all information I have provided in this ‘form’ is true and correct.
I certify that all information verbally transmitted to the doctor is true and correct. I am seeking medication(s) or service(s) for my own, personal, medical use. I am aware that if any of my document(s) are lost or stolen medical document(s) replacement fee(s) may apply.
(415) 966-0848 1884 Market St San Francisco, CA 94102
EzCare Medical Clinic. All rights reserved.