All customers wishing to buy prescription items must complete this form and mail or fax it to us prior to shipment of any prescription item order. Please have your authorizing physician complete the form below, or, if your organization is licensed to purchase prescription products, complete the appropriate sections and attach a copy of your current drug license. Customer Name: _________________________________________ Attention: ________________________________________________________ Customer Address: ________________________________________________ Telephone: _____________________ Fax: _____________________ Authorization to Purchase: City: _____________________________ State: ________ Zip: ____________ Customer Account Number: __________________________________ I authorize the designated representatives of the organization listed above to purchase the following prescriptions items: V.E. RALPH & SON, INC. Prescription Item Authorization Form ______ Needles, Syringes, IV Fluids and Administration Sets ______ Other ( please specify ________________________________________ ) Physicians Name: _________________________________________________ Address: _________________________________________________________ ________________________________________________________________ Physicians Signature: ______________________________________________ Phone: ________________ Fax: _______________ E-mail: _______________ Mail or fax the completed form to: DEA Reg. No:__________________ State License No. ___________________ V.E. RALPH & SON, INC. PO BOX 633, KEARNY, NJ 07032-0633 FAX: 1-800-772-7203 TEL: 1-800-526-1196 98 1-800-526-1196 · www.veralph.com V.E. RALPH
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