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Get Pharmacist's Manual - SECTION IX-XIV - DEA Diversion Control

Their choice. Prescription Referral Form Send your Rx to: avella.com If you have questions or concerns, please contact us. Choose Location Date Medication Needed: Ship To: Patient s Home Prescriber s Office Injection training by pharmacy? Pick-up (store location): 1: Patient Information Patient Name: Birthdate: Soc. Sec. #: Sex: Preferred Phone: Male Height: Female Weight: lbs. kg. Known Allergies: Address: City: Alternate Caregiver Name: State: Zip: Preferred.

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