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C iverseReturn and DestructionLog <br /> • Returns are limited to tablets and capsules In blister cards and manufactured sealed packages of <br /> other items. Please place re-order strip from pharmacy label in space provided. Indicate quantity and <br /> reason for return. Make copy for facility records and send original with returned medications. <br /> aAly <br /> Facility Name Your Name Date <br /> Delivery/CourierDriver Signature: <br /> (Required) <br /> Credit Issued <br /> Qty NO YES Tech " <br /> 1 Rec'd (use key) Initials <br /> 0 <br /> v u <br /> J <br /> O <br /> N <br /> � r�3 <br /> E q <br /> a� <br /> co <br /> rw <br /> 0 <br /> ao <br /> O 1W <br /> W <br /> tfi� <br /> in <br /> ®a <br /> Wt <br /> O t <br /> LL <br /> a <br /> d <br /> "( REA�N'-KEY We hereby certify that these drugs were disposed of as required by law: <br /> ,.:�ss3turn 1p R oretstac(F#eturf�to Rc °a=ltfeT tc R <br /> Pharmacist <br /> d H <br /> (FieturfttfsRx) fie t# sr Registered Nurse <br /> Licensed Nurse <br /> z e <br /> Dat <br /> " <br /> :..::�._. .. :. ...�: ...x.... "...�v�� a a�:-`i... ,.a._..x.., ....,... ._ ..:a .. .m.:..... ..I3., ....,£..•r. �, ......,.. :....... ......... .. ........_. ... <br /> i{3.. <br />