MARCUS A. EAST, M.D.
RYAN W. LAPOUR, M.D.
JOHN G. DODD, D.O.
ADAM T. SHUPE, O.D.

Patient Name:
DOB:
Patient Phone:
Provider:
Written On:
Prescription:
Sig:
Quantity:
Size:
Refills:

X   SUBSTITUTION PERMITTED
X   DISPENSE AS WRITTEN

State Lic:  
State: OR
DEA:
655 Medical Center Dr. NE
Salem, Oregon 97301
503.581.5287
Fax 503.386.1377
mceyeclinic.com