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Get Gu Dhss Application To Prescribe Administer And/or Dispense Controlled Substances

6 Mail to address below Pick-Up Point of Contact: Contact Number: APPLICATION TO PRESCRIBE, ADMINISTER, AND/OR DISPENSE CONTROLLED SUBSTANCES PLEASE TYPE/PRINT CLEARLY AND ACCURATELY New Renewal Re-issuance Amendment 1. Applicant s Name: Phone: 2. Pharmacy/Clinic: Phone:.

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