TA:_________Bot:________
Torb:________Bot:________
X:________
Euth:________Bot:________
Time:________Date:_____________
Clinician Signature:_____________________________
Euth$______ After$______Misc$______ Total$______
Cash ____Check#______ Credit Card Last 4: ______________
Drug Log:________ Card Sent:_______ Email Sent:_______