www.marshallortho.com

Douglas A. Waldman, MD

 TX License E-6674 -- AW

 NPI 1902801871 / TX DPS D0127308

304 University, Suite 212      Marshall, Texas 75670-5247

Phone [903] 935-1151 -- Fax [903] 935-0077

PRESCRIPTION

[GENERICS OK]

Patient Name:

Patient address:

Patient DOB or Age:

Medication : 

Dispense :

Refill: 

Directions :

 

____________________________________________________________________

                                Douglas A. Waldman, MD

Date:

PLEASE CALL IN OR FAX IN TO :

OK TO DISCARD THIS SHEET AFTER Rx IS RECORDED IN OFFICE CHART