- Name of Supplier: Southern Anesthesia & Surgical, Inc.
- Street Address: One Southern Court
- City and State: West Columbia, SC 29169
- Date: Today's Date (the date you are filling out the form)
- Number of Packages:The quantity of drug being ordered
- Size of Package:The size of the drug being ordered (ie. 20ml, 10x5ml)
- Name of Item:The name and description/strength of the drug being ordered (ie. Fentanyl vial, Fentanyl amps, Demerol 50mg/ml)
- Last Line Completed:This number should correspond to the Line No. of the last line on which a product was ordered
- Signature of Physician or Power of Attorney:Unsigned forms cannot be processed
Mistake anywhere on the form? You will need to VOID your entire form, keep it on file and start with a new one. Please do not write over mistakes in an attempt to correct. This is considered an alteration. We cannot accept forms with alterations or errors.
Retain the bottom copy (Blue) for your records.
The remainder of the form can be mailed to us.