Patient Consent Form

I date of birth , cell phone number , hereby consent to the sharing of my pharmacy data with Health Window or Health Window's successor in title for the past 12 months and until I withdraw this consent. I have been informed of the Health Care Co-ordination services, and have read, understand and agreed to the terms and conditions of it.

Please sign below:

For more information:

Contact us via:

Email:

info@healthwindow.co.za

Phone:

012 844 9000

For more information please contact your pharmacy directly