Acknowledgement of Ability to Receive Written Prescription

Acknowledgement of Ability to Receive Written Prescription
I understand my right to receive a written prescription for medication that can be filled at the pharmacy of my choice or by my veterinarian, as provided in s. 474.224, Florida Statutes.
Name

First NameLast Name
Signature
Date

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2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: