77 Ill. Adm. Code 2085.EXHIBIT E
E Research Order for Delta-9-Tetrahydrocannabinol
Section 2085
Section 2085.EXHIBIT E Research
Order for Delta-9-Tetrahydrocannabinol
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