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By submitting this form or calling, I confirm this will serve as my signature authority for Beacon, American Wellness, and their subsidiaries/suppliers or its customers to call me on my telephone at the number provided. I am aware of my rights to protect my privacy and these rights are waived for the purpose of Beacon, American Wellness, and their subsidiaries/suppliers or its customers to call me. By submitting this form or calling, I am giving my permission for my doctor to be called, faxed, and receive follow up calls at any point before or after I receive my shipment. All orders are subject to doctor approval for medical necessity. I consent to receive information regarding potential remedies for your ailments on this phone call or subsequent phone calls until such a point I indicate not to do so. I further my consent to receive phone calls regarding Insurance products or other healthcare related products at later times until such point I specify to not call me. Service will be conducted by one of Beacon, American Wellness, and their subsidiaries/suppliers or its customers. I am permitting calls to be automatically dialed. All calls will be recorded. If I am on a do not call list, by opting in, I am waiving this right. Copays and deductibles apply. I understand that I am not required to provide my Consent as a condition of purchasing any products or services, and this offer does not qualify me for any prizes or rewards. Message and data rates may apply.

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