VOID
Provider Name: _______________________
Superhero Family Practice, INC
1234 Kryptonite Way
Superhero City, Superhero State 12301
(800) 123-4567
Patient Name: ____________________________________________________ Date: ____________
Address: _________________________________________________________ DOB: ____________
License: ___________ NPI: _____________ DEA ( Controlled Substances Only): ______________
DISPENSE AS WRITTEN (DAW) Generic Substitution Permitted
Signature of Provider Signature of Provider