5 1/2" x 4 1/4" Horizontal - Standard 24# Bond Paper (100 sheets/pad: 8 pads minimum) - Blue

Clinic or Business Name

Specialty

Address

City

State

Zip Code

Phone #

Fax #

1 - Prescriber Name

1 - License #

1 - DEA #

2 - Prescriber Name

2 - License #

2 - DEA #

3 - Prescriber Name

3 - License #

3 - DEA #

4 - Prescriber Name

4 - License #

4 - DEA #

Deliver every
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