Patient Rules

 

TeleGram Collective requires a signed Patient Rules form prior to making a donation for any Medicinal products from our Pharmacy. Please complete the form below and return to us.

Digital Signature UploadManual Signature UploadUpload
1.Select Click to Download link below.
2.Initial, Sign and Date digitally (learn how).*
3.Upload.
1.Select Click to Download link below.
2.Print form.
3.Initial, Sign and Date.
4.Scan.
5.Upload.
1.Click Choose File button.
2.Navigate to your file.
3.Click Submit button.

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* Note:  If your default viewer is not Adobe Reader, please download, save and  reopen doc in Adobe Reader (right-click > open with > Adobe Reader). If you do not see option for Adobe Reader, you can (download free here).

Click to Download