8290 SW State Rd 200, Ocala, FL 34481

202 SW 17Th St Ste A, Ocala FL, 34471

DIM

Dosage Form

Quanity

Strength

Clear

Product Name

Quanity

Dosage

Strength

Refills

Notes for custom strength, quantity, ect.

Directions for use

Patient Information

Patient Name

Patient Phone

Patient Date of Birth

Street

City

State

Zip Code

Bill to

Office

Patient

Ship to

Office

Patient

Patient Pickup at Pathway Pharmacy

Preferred Shipping Method

Ground

Second Day

Pickup

Delivery

Prescribed by

DEA Number

SKU: N/A Categories: Practitioners, Women’s Health

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