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:
U.J. Berzins, M.D.
Robert E. Tibolt, M.D.
Marcus A. East, M.D.
Ryan W. Lapour, M.D.
John G. Dodd, D.O.
Adam T. Shupe, O.D.
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
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