Dentrix Practice
1234 Valley Dr.
American Fork, UT 84003
TELEPHONE: (801)555-9087
DEA REG. NO.: 1234567
NAME
Patricia Abbott
DOB
09/30/1963
ADDRESS
608 S 500 W
Murray, UT 84123
DATE
09/09/10
Rx
REFILL 0 TIMES
LABEL
DISPENSE AS WRITTEN
VOLUNTARY FORMULARY PERMITTED
SIGNATURE OF PRESCRIBER
IF NEITHER BOX IS MARKED, A VOLUNTARY FORMULARY PRODUCT MUST BE DISPENSED.