THE SIGNER ACKNOWLEDGES RECEIPT OF
THE PRESCRIPTION FOR AN ELIGIBLE RECIPIENT,
AND ALSO THAT PHARMACIST COUNSELING HAS BEEN OFFERED.
The signature log is 8 1/2" x 11", printed in blue ink
on one side of 20 lb. white bond paper.
The forms are made up in pads of 100 and
pre-drilled for convenient
filing in a standard 3-ring notebook.