AIDS Healthcare Foundation

PATIENT PHARMACY SERVICES AGREEMENT

Carlos Eduardo Vergel Guerra

_________________________________________________________________
02.17.1990
_______________
Patient Name (Please Print)/Pronoun Date of Birth
No
Known Allergies_____________________________________________________________________________________________
60 maple St NE House 60 Farmingdale
______________________________________________________________________________________________________
New York 11735
Address and Street Apt. # City State Zip Code
Jose Antonio Amigos +1 (347) 832-9772 Yes
________________________________________ ______________________________ ______________________ _____
Emergency Contact Name Relationship Phone Cell

REFILL MANAGEMENT PROGRAM

We will contact you on a periodic basis to remind you that we are refilling all of your maintenance medications and to check to see if there are
changes in your information and medications. Please note that most insurance plans require that we be in contact with you on a regular basis and
could result in a delay if we cannot reach you.
What is your preferred method of contacting you?

✔Telephone ✔Text Email

✔ Preferred Language Spanish

305-390-6429
Phone: ___________________________
Carveredu770@gmail.com
Email: ________________________________________
Cv
Patient Initial_______

DELIVERY OPTIONS*
You may wish to pick-up your medications each month from the pharmacy, have them delivered by an AHF Pharmacy Services Liaison or have them
mailed or shipped. You may change at any time.
✔Prefer Home Delivery (Courier, SF residents only) ✔
Prefer U.S. Mail
May Leave if not home ✔Prefer FedEx

May be left with someone other than you Prefer to Pick-Up

__________________________________________ _____________________ ________________

Name Relationship Phone No
Alternate Address for Delivery, Mail or Shipping
Cv
_______________________________________________________________________________ Patient Initial _______
*Schedule II controlled substance prescriptions require a signature

CREDIT CARD ON FILE

Yes, keep my credit card on file for prescription cost not payable by my insurance plan.
Yes, keep my credit card on file, obtain my authorization before charging to my card.
No, I will provide you with payment at time of purchase. Patient Initial ____________

Special Instructions: __________________________________________________________________________________

DISCLOSURES
1. AHF cannot ensue the security of messages sent by email or text, as these message travel over the internet, and we have no control over the
security of the device that receives the messages. Upon request, we may be able to arrange for transmission of encrypted emails. Please contact your
AHF pharmacist if you would like to try this option.
2. Note to Patient: By completing and signing this form, you authorize AHF Pharmacy and staff to send protected healthcare
information to you and receive that information from you by email, messenger apps, other electronic tools and/or text messaging that
could include, for example, information about prescriptions, test results, diagnoses, appointments, and reminders. By signing this
authorization, you accept any risk involved in sending your health information by email, messenger apps, other electronic tools and/or
text messaging. Even if you opt to communicate with us by email, messenger apps, other electronic tools or text messaging, you will
always be able to communicate with us by phone and mail.
___________________________________________________________ 02.16.1990
_______________
Carlos Vergel (Feb 16, 2024 11:15 EST)

Patient Signature: Date: