STATE OF ILLINOIS

ORDER SERIAL

NUMBER

(Name of Hospital)

No.

DANGEROUS

DRUGS

COMMISSION

(312) 822-9860

(Address & ZIP Code)

(Pharmacy DEA Number)

RESEARCH ORDER FOR DELTA -9- TETRAHYDROCANNABINOL

Valid for ONE bottle of NOT MORE THAN 25 capsules at above pharmacy ONLY.  ORDER NOT REFILLABLE.

PATIENT'S NAME:

DATE:

PATIENT'S ADDRESS:

ZIP:

PERIOD COVERED BY THIS ORDER:

198

TO

198

AGENT (if applicable):

ORDER:

DELTA-9-THC AT

MGS

AT

CAPSULES,

(Strength)

(Quantity written in longhand)

SIG:

PATIENT IS TO RETURN UNUSED MEDICATION,

I AFFIRM THAT INFORMED PATIENT CONSENT HAS BEEN OBTAINED.

M.D.

(Patient's Signature)

M.D.  ILL CONTROLLED SUBS NO:

M.D. FEDERAL DEA NO:

DATE FILLED:

M.D. HOSPITAL AFFILIATION:

RECIPIENT'S

SIGNATURE:

VERIFICATION

OF RECIPIENT:

REG PHARMACIST'S

SIGNATURE & NUMBER:

DDC FORM 299 (Series October 1980) Retain original in pharmacy; forward duplicate to DDC