Masune First Aid & Safety
500 Fillmore Ave.
Tonawanda, NY 14150		  
Fax: 1-800-222-1934
Phone: 1-800-831-0894
24 Hours/Day, 7 Days/Week
     

Prescription Drug & Medical Device Authorization Form
If purchasing prescription pharmaceuticals, please complete sections A & B.
If purchasing an Automated External Defibrillator (AED), Muscle Stimulator or Ultrasound unit, complete sections A & C.
   

Dear Valued Customer:

In order to ship prescription pharmaceuticals to you, we must have an authorization from a licensed physician or other authorized prescriber. Please have a licensed physician, or other authorized prescriber, fill out the form below and return this entire form to us, together with a photocopy of his/her license(s).

If your facility does not have a licensed physician or other authorized prescriber, but is licensed to purchase prescription products, please send us a copy of the license, along with this form for identification. Thank you!
   
A) Name of Company/Organization/Institute: __________________________________________________
Attention: _____________________________________________ Customer #: __________________
Address: _____________________________________________________________________________
  City, State: _______________________________________________ Zip:_____________________
Phone: ______________________________________ Fax:__________________________________
   
B)  I hereby authorize the internally designated representatives named below to order prescription products for this Company/Organization/Institute. (Please print)
1. ____________________________________ 2. ______________________________________
  Type of authorization: Unlimited Limited (please attach a list products)
Physician/Authorized Prescriber Signature: __________________________________________________
Name (PRINT): ______________________________________Date: ____________________________
DEA Registration Number: ________________________________ (please include photocopy of license)
State License Number: ___________________________________ (please include photocopy of license)
 
C) I hereby acknowledge that I am aware that the following Medical Devices: Automated External Defibrillator (AED), Muscle Stimulator or Ultrasound unit are intended for use by a physician or a person licensed by state law.
Name (PRINT): ____________________________________Title: _____________________________
  Signature: ______________________________________________Date: ______________________