INFORMATION SHEET
(CONTINUED)
Please use this sheet
to indicate prescription(s) that have been sought
or obtained by the suspect which are not listed in the previous forms
ONLY OCCURANCES
WHEN SUSPECT SOUGHT OR OBTAINED PRESCRIPTIONS
FOR NARCOTICS OR CONTROLLED DRUGS ARE OF INTEREST FOR COURT
PURPOSES.
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PRESCRIPTIONS
SOUGHT AND/ OR OBTAINED
|
DID
PERSON ADVISE YOU OF ANY PRESCRIPTIONS OF NARCOTICS OR CONTROLLED
DRUGS THAT WAS SOUGHT IN THE LAST THIRTY DAYS FROM OTHER DOCTORS? |
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DATE
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TYPE
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STRENGTH
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QUANT.
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YES
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NO
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PRACTITIONER'S SIGNITURE:
______________________________________
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