Quality Rx Returns

*Name

*Address

*City, State Zip
,

*Contact

*Phone

*Fax

*DEA#

*DEA Expiration

*Wholesaler

*Address

*Account Number

Item 1

Number of Packages

Package Size

NDC #

Name of Item

Item 2

Number of Packages

Package Size

NDC #

Name of Item

Item 3

Number of Packages

Package Size

NDC #

Name of Item

Item 4

Number of Packages

Package Size

NDC #

Name of Item

Item 5

Number of Packages

Package Size

NDC #

Name of Item

Item 6

Number of Packages

Package Size

NDC #

Name of Item

Item 7

Number of Packages

Package Size

NDC #

Name of Item

Item 8

Number of Packages

Package Size

NDC #

Name of Item

Item 9

Number of Packages

Package Size

NDC #

Name of Item

Item 10

Number of Packages

Package Size

NDC #

Name of Item