FAMILY PLANNING HEALTH SERVICES, INC

PILL PICK UP PERMISSION SLIP

I___________________________________, DATE OF BIRTH_______________________,

Give the following people listed, permission to pick up my pills

I will notify the clinic should I want a name added or deleted from this list.

SIGNATURE_________________________________________________ DATE__________

NAME RELATIONSHIP

1.__________________________________________ _____________________________

2____________________________________________ ____________________________

3____________________________________________ ____________________________

4____________________________________________ ____________________________

5____________________________________________ ____________________________

FAMILY PLANNING HEALTH SERVICES, INC

PILL PICK UP PERMISSION SLIP

I___________________________________, DATE OF BIRTH_______________________,

Give the following people listed, permission to pick up my pills

I will notify the clinic should I want a name added or deleted from this list.

SIGNATURE_________________________________________________ DATE__________

NAME RELATIONSHIP

1.__________________________________________ _____________________________

2____________________________________________ ____________________________

3____________________________________________ ____________________________

4____________________________________________ ____________________________

5____________________________________________ ____________________________