EA Patient Nam Address / 5 NLIIVIRER City // / , t"- ` 1 ,,,.. , .4. , / / , Prescri ,er / , / Sig ture X ,.41,115 PRE CRIPTION WILL BE FILLED GENE S REFILLS ACIST AREA: TES ter,..... \ , Preferred Language -, -, 4c3(tion errots Pleate set \ Dispense As Written / / / / /7. te , 4,, s , \ `\ , \\\ 4 ' preficriptio:rF 4 ; \ , MAXIMUM DAILY DOSE ,\\ (controlled substances only) SS PRESCRIBER WRITES 'claw' IN THE BOX BELOW Illikiliii111111119111111 \ " - EFTA01201947