Physician's License

Physician's Name
License Number
Expiration Date
Facility Name
Facility Address
Address Line 2
This letter is to state that I, ______________________ ,am designated as the Medical Director/Supervisor for the above listed facility, and the internally designate representative(s) of this facility are allowed to acquire legend drugs and/or devices under my legal authority.
Physicians's Signature

Clear
Additional Authorized Facilities
Facility Name:
Facility Address:
Should be Empty: