Patien Name* DOB* Phone Number* CONSENT TO MAIL MEDICATIONS TO MY HOME GENERAL INFORMATION I understand Georgia Spine & Orthopaedics (GSO”) is licensed to dispense certain medications (“Medications”). I understand GSO is willing to mail Medications to my home address via First-Class Mail. I understand there is a risk, however, that: (i) someone may steal Medications out of my mailbox, (ii) a family member or other person authorized to collect the mail from my mailbox may wrongfully take Medications, (iii) Medications may get lost or stolen in transit from their office to my mailbox, or (iv) Medications may be delivered to the wrong address. Additionally, a collateral risk of mailing Medications is that my Protected Health Information (PHI) is discovered by an unauthorized party. I understand GSO is not responsible if sending Medications results in an unauthorized person seeing my PHI or obtaining Medications. Knowing these risks and accepting the liability and responsibility for same, I agree and authorize GSO to mail my Medications to my home address. ACCEPTANCE, CONSENT, AND WAIVER I agree to allow GSO to mail my prescriptions directly to the address I provided. This mailing will include my PHI, such as my name and the medication that I am taking and may include other sensitive facts about my health. I understand that if another person accesses my prescription, that person will see my PHI. If I do not want to accept the risk that someone may take my prescription and/or access my PHI, I should not agree to allow GSO to mail my prescriptions to me. I accept these risks and agree that GSO may mail my prescriptions to me via First-Class Mail. I agree to inform GSO immediately if my address changes. I will not hold GSO responsible if my PHI is seen by an unauthorized person or my medications are taken/obtained by an unauthorized party. I RELEASE, WAIVE, DISCHARGE AND PROMISE NOT TO SUE OR BRING ANY CLAIM OF ANY TYPE AGAINST GSO FOR LOSS, DAMAGE, INJURY, OR LIABILITY RELATING TO THE MAILING OF MY MEDICATIONS TO MY DESIGNATED ADDRESS. PATIENT ACKNOWLEDGMENT This form gives you the facts about and risks involved in receiving my Medications by mail. By accepting this form, I confirm that I have read, understand, and agree with these Terms of Use for receiving my Medications by mail. My acceptance of this form indicates that I freely consent to receive my medications from GSO by mail to the address that I provided. I also confirm by accepting this form that: I have been able to ask any questions. All my questions have been answered. No guarantees have been made. I agree to the terms as noted above. Patient Home Address* By accepting these terms, I acknowledge having the choice between obtaining my medications from GSO or at a pharmacy of my choice. Patient Signature*