Missouri Department of Health and Senior Services



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|DRUG NAME & STRENGTH | |Page # | |BALANCE ON |YEAR | |

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|NUMBER |DATE |PATIENT NAME |PATIENT ADDRESS |(-) AMOUNT |(+) AMOUNT |BALANCE |DISPENSER |PHYSICIAN |

| | | | |DISPENSED |RECEIVED |BROUGHT FORWAD|INITIALS |NAME |

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MISSOURI DEPARTMENT OF HEALTH & SENIOR SERVICES

BUREAU OF NARCOTICS AND DANGEROUS DRUGS

CONTROLLED SUBSTANCE DISPENSING OR ADMINISTRATION LOG

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