PHARMACY PRESCRIPTION AUTHORIZATION/REQUEST FORM
LOGOATLANTA WEIGHT LOSS & WELLNESS ASSOCIATES
 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
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