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Rx Consent Form
Medication/Prescription Delivery
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* Indicates required question
I give Woosh Delivery permission to transport and deliver my medications/prescriptions until further notice.
*
YES
Today's Date
*
MM
/
DD
/
YYYY
Name
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Address (please include name of city/town)
*
Your answer
*Woosh Delivery can not be held responsible for pharmacy errors. Please contact your pharmacy with any concerns/issues. Do you Agree to these terms and conditions?
*
Yes
No
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