Original Carbon Copy Form
Requirements for Properly Completed 222 Forms:
DEA requires that your 222 form address be the same as the address on your current DEA Certificate. DO NOT fill out Suppliers DEA Registration No., National Drug Code, Packages Shipped and Date Shipped. This information will be completed by Southern Anesthesia & Surgical, Inc. on the brown and green copies after your order has shipped. Any questions? Call us at 1.888.222.3722.
Code on Sample form (to the right, click to enlarge)
- 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.
*If the signature is anyone other than the Registered Physician, we must have a copy of the Power of Attorney on file
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.
Click here to view the Original Carbon Copy form