Informed Consent for Shipping/Delivery of Prescriptions Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Consent(Required) I agree to the Agreement of Terms.I have discussed this service with my medical practitioner or his/her representative and/or NextGenRx representative and affirm my desire to utilize NextGenRx for my prescription and be sent directly to me. I understand that NextGenRx will do everything possible to decrease and minimize the delay of delivery of my prescription order but that there are no guarantees that these measures will be effective at preventing loss or delay of delivery of my medication. I accept the risks and unknowns of having my prescription orders delivered by USPS/UPS/FEDEX/Pharmacy Delivery.NameThis field is for validation purposes and should be left unchanged.