DS W4

FOR CLASSROOM USE ONLY

Refills:

May Substitute: Signed:

DEA:

Rx:

Name: Date: DOB/Age:

Use this in your case studies when asked to provide a prescription. Please paste it into the paper

with the question that is asking for it. If you have problems, first select Insert, then text box in your paper, copy the content from the Rx and paste it into the box.