Pharmacy Consent Form

Please correct the errors described below.

I voluntarily authorize Ellahi HeartClinic/ Atif Soahil, M.D. to electronically transmit prescriptions to the pharmacy of my choice: review pharmacy benefit information and medication dispense history as long as I am a patient in his office or until I withdraw my consent in writing.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Please select Drug & Strength

Beta Blockers:

Ace Inhibitors:

Calcium Antagonists:

Angiotensin II Receptor Blockers:

Diuretics:

Your information will be encrypted.

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