THE FACE OF THIS DOCUMENT HAS A GRAY BACKGROUND
Telephone: (816)555-1212
Fax: (816)-555-5555
DEA # MB1234567
DEA# QB 1234789
JOHNSON COUNTY MEDICAL CLINIC
Ian McCombs, MSN, FNP, APRN-BC
John Roberts, DNP, FNP, APRN-BC
1211 Main Street
Maple, MO, 64041
Name_____________________________ Date of Birth _________________Date___________________
Address______________________________________________________________________________
RX
Refill- 0-1-2-3-4-PRN
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Substitution Permitted
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Dispense as Written