PHARMACY PRESCRIPTION AUTHORIZATION/REQUEST FORM
LOGOATLANTA 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
 
PHARMACY PRESCRIPTION AUTHORIZATION/REQUEST
 +
 +
Pickup Instructions *
HCG Programs *
0/200 characters
 +
Licensed Provider Signature:
clear
Physician Signature:
Secured by Formsite