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Prescription Drug Fraud logoPrescription Fraud Preliminary Report

Please sign and fax Affidavit at bottom of page


Incident Information
Format: h:mm am/pm
Prescription Information
Payment Information
Manner Ordered
Additional Information
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Pharmaceutical Drug Diversion brochure

  • Affidavit - please sign the affidavit and fax it to 615-782-3354 so we can resolve this matter quickly.