GME Division of Medical Education
Graduate
Medical Education
UCSD Medical Center

CONTROLLED SUBSTANCE SECURITY PRESCRIPTION PAD ORDER FORM

Date:   New Order, fax copy of DEA to 619-543-7859    Reorder
Department Name:
 Telephone Number:
Contact Name:
 Email Address:
MULTIPLE PRESCRIBERS ON ONE FORM
On multiple prescriber forms, one of the listed prescribers must sign and accept responsibility for all the pads. This responsibility includes accepting delivery of and future control/issuance of the pads. Physician assuming responsibility: Responsible Physician's Email Address:
Quantity of Pads Requested (100/pad):
PRACTITIONER IMPRINT INFORMATION
Last Name First Name MI Degree Specialty DEA No. License
No.		 Qty:
(100/pad)
3 pads
10 pads
3 pads
10 pads
3 pads
10 pads
3 pads
10 pads
3 pads
10 pads
3 pads
10 pads
3 pads
10 pads
3 pads
10 pads
3 pads
10 pads

Please return to Forms Management: MC8491, 619-543-7859 (fax).

D940(11-05)

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