PHARMACY PRESCRIPTION AUTHORIZATION/REQUEST

ATLANTA WEIGHT LOSS & WELLNESS ASSOCIATES
155 Westridge Pkwy* Ste 307*McDonough, GA 30253
Mobile & Tele-Services Provider

Miguel E. Stubbs, MD Lic# 03770

Sabrina M. Lee, BSN, RN

Phone (678) 289-0006 * Fax (404) 920-3469

New or Existing Client *

Purchase Date +

Date Desired +

Pickup Instructions *

Profile

Call Client When Ready

Staff Will Pickup

Client Contact Number *

Last Name *

First Name *

Date of birth: *

Street Address

City *

State *

Medication or Food Allergies: *

HCG 5000IU/10ml Bacteriostatic H20 (125 IU SQ DAILY) INJECT 25 Units Subcutaneously daily (ABDOMEN OR THIGHS)

Syringes 10Pk (Insulin Syringes)31 gauge, 0.3 or 0.5 ml, 5/16”

B-Complex w MIC + L-Carnitine (Lipovite) 1ml IM weekly

Hi-Potency B-Complex w MIC + L-Carnitine 1ml IM weekly

Additional Details

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CALLED/EMAILED TO :

Date Requested +

Time Requested

Requested By:

Licensed Provider Signature:

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Physician Signature: