Telephone Order Form 3-Part

Briggs Form 982 includes a check-off audit block.

The last part on this form serves as a temporary copy as well as the mount sheet once the signed original is returned. Routing is as follows:

·         ORIGINAL COPY-Physician Please Sign and Return

·         PHARMACY COPY-Send to Pharmacy

·         CHART CONTROL COPY-Attach Original Signed Copy When Received

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