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Consent to Obtain Prescription History

This consent form authorizes ReviveMD, to obtain and review my prescription history. A detailed prescription history will provide my ReviveMD medical provider information about medications prescribed by other providers involved in my medical care. This information will improve the accuracy of the names and dosages of the medications in my ReviveMD medical record and will help avoid adverse drug reactions.

By signing this consent form, I agree that I understand and have given informed consent for ReviveMD to request and use my prescription medication history from other healthcare providers, pharmacies, and benefit payors (such as my insurance company) for treatment purposes.

I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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