PART 5: TO BE FILLED IN BY NUMBER REC’D REC’D DATE PURCHASER DEA FORM-222 U.S. OFFICIAL ORDER FORMS - SCHEDULES I & II DRUG ENFORCEMENT ADMINISTRATION OMB APPROVAL No. 1117-0010 NATIONAL DRUG CODE NUMBER DATE SHIPPED SHIPPED ITEM NO. OF PACKAGES PACKAGE SIZE NAME OF ITEM PART 3: ALTERNATE SUPPLIER IDENTIFICATIOM PART 4: TO BE FILLED IN BY SUPPLIER ALTERNATE DEA # Signature- by first supplier TRAVIS, BARBER HAPPY PETS VETERINARY SUPPLY REGISTRATION INFORMATION PURCHASER INFORMATION SUPPLIER DEA NUMBER:# PART 2: TO BE FILLED IN BY PURCHASER PART 1: TO BE FILLED IN BY PURCHASER BUSINESS NAME STREET ADDRESS CITY, STATE, ZIP CODE REGISTRATION #: RB000000 REGISTERED AS: PRACTITIONER SCHEDULES: 2,2N,3,3N,4,M5 ORDER FORM NUMBER: 000000000 ORDER FORM: 3 OF 3 DATE ISSUED: 11102019 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 CAMBRIDGE, MA 02141IPSUM 3949 LYNN STREET OFFICIAL AUTHORIZED TO EXECUTE ON BEHALF OF SUPPLIER (name in part 2) if order is endorsed to another supplier to fill - to be filled in by first supplier DATE Date Print or Type Name and Title Signature of Requesting Official (must be authorized to sign order form) Your Name and Title CODEINE 15MG TABS 100CT 1 Woodfield Distribution, LLC R W 0 4 0 7 0 7 6 951 Clint Moore Rd, Suite A Your Signature Today’s date Boca Raton, FL 33487 LAST LINE COMPLETED (MUST BE 20 OR LESS) 5 4 Include our supplier DEA number. The Number is RW0407076 1 Authorized name and title 2 Authorized signature on the form. 3 Fill in the date the form is completed. 8 Please write the correct size and strength. 7 DO NOT WRITE PASS THIS LINE. 6 Make sure the street address is correct. 951 CLINT MOORE RD, SUITE A BOCA RATON, FL 33487 9 Fill in the Last Line Completed space. Make sure the name of the Supplier is correct. WOODFIELD DISTRIBUTION, LLC CODEINE 30MG TABS 100CT 1 CODEINE 60MG TABS 100CT 1 DURAMORPH 1MG/ML 10ML 10BX 2 FATAL PLUS SOLUTION 250ML 1 FENTANYL 50MCG/ML 50ML VIAL 25BX 2 FENTANYL 50MCG/ML VIAL 50ML 2 FENTANYL PATCH 12MCG/HR 5BX 1 HYDROCODONE 5MG-1.5MG TABS 100CT 2 HYDROCODONE SYRUP 5MG-1.5MG/5ML 473ML 1 HYDROMORPHONE 2MG/ML 1ML VIAL 25BX 2 HYDROMORPHONE 10MG/ML SDV 50ML 3 HYDROMORPHONE 10MG/ML 5ML 10BX 2 HYDROMORPHONE 2MG/ML 20ML 1 METHADONE 10MG/ML VIAL 20ML 2 MORPHINE SULFATE 10MG/ML 1ML VIAL 25BX 3 MORPHINE SULFATE P/F 1MG/ML 10ML VIAL 5BX 2 MORPHINE SULFATE 50MG/ML VIAL 20ML 1

Your Name and Title Your Signature Today’s date Applications/NetSuite Inc...2 5BX MORPHINE SULFATE P/F 1MG/ML 10ML VIAL 1 20ML MORPHINE SULFATE 50MG/ML VIAL Title DEA 222 Forms Received

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Page 1: Your Name and Title Your Signature Today’s date Applications/NetSuite Inc...2 5BX MORPHINE SULFATE P/F 1MG/ML 10ML VIAL 1 20ML MORPHINE SULFATE 50MG/ML VIAL Title DEA 222 Forms Received

PART 5: TO BE

FILLED IN BY

NUMBERREC’D REC’D

DATE

PURCHASER

DEA FORM-222 U.S. OFFICIAL ORDER FORMS - SCHEDULES I & II DRUG ENFORCEMENT ADMINISTRATION

OMB APPROVAL No. 1117-0010

NATIONAL DRUG CODENUMBER DATESHIPPED SHIPPEDITEM NO. OF

PACKAGESPACKAGE

SIZE NAME OF ITEM

PART 3: ALTERNATE SUPPLIER IDENTIFICATIOM

PART 4: TO BE FILLED IN BY SUPPLIER

ALTERNATE DEA #

Signature- by first supplier

TRAVIS, BARBERHAPPY PETS VETERINARY SUPPLY

REGISTRATION INFORMATION PURCHASER INFORMATION SUPPLIER DEA NUMBER:#

PART 2: TO BE FILLED IN BY PURCHASER

PART 1: TO BE FILLED IN BY PURCHASER

BUSINESS NAME

STREET ADDRESS

CITY, STATE, ZIP CODE

REGISTRATION #: RB000000REGISTERED AS: PRACTITIONERSCHEDULES: 2,2N,3,3N,4,M5ORDER FORM NUMBER: 000000000

ORDER FORM: 3 OF 3 DATE ISSUED: 11102019

CAMBRIDGE, MA 02141IPSUM3949 LYNN STREET

OFFICIAL AUTHORIZED TO EXECUTE ON BEHALF OF SUPPLIER

(name in part 2) if order is endorsed to another supplier to fill- to be filled in by first supplier

DATEDate

Print or Type Name and Title

Signature of Requesting Official (must be authorized to sign order form)

Your Name and Title

CODEINE 15MG TABS100CT1

Woodfield Distribution, LLC

R W 0 4 0 7 0 7 6

951 Clint Moore Rd, Suite A

Your Signature Today’s date

Boca Raton, FL 33487

LAST LINE COMPLETED (MUST BE 20 OR LESS)

4Include our supplier DEA number. The Number is RW0407076

1Authorized name and title

2Authorized signature on the form.

3Fill in the date the form is completed.

8Please write the correct size and strength.

7DO NOT WRITE PASS THIS LINE.

6Make sure the street address is correct. 951 CLINT MOORE RD, SUITE ABOCA RATON, FL 33487

9Fill in the Last Line Completed space.

Make sure the name of the Supplier is correct.WOODFIELD DISTRIBUTION, LLC

CODEINE 30MG TABS100CT1CODEINE 60MG TABS100CT1DURAMORPH 1MG/ML 10ML10BX2FATAL PLUS SOLUTION250ML1FENTANYL 50MCG/ML 50ML VIAL25BX2FENTANYL 50MCG/ML VIAL50ML2FENTANYL PATCH 12MCG/HR5BX1HYDROCODONE 5MG-1.5MG TABS100CT2HYDROCODONE SYRUP 5MG-1.5MG/5ML473ML1HYDROMORPHONE 2MG/ML 1ML VIAL25BX2HYDROMORPHONE 10MG/ML SDV50ML3HYDROMORPHONE 10MG/ML 5ML10BX2HYDROMORPHONE 2MG/ML20ML1METHADONE 10MG/ML VIAL20ML2

MORPHINE SULFATE 10MG/ML 1ML VIAL25BX3MORPHINE SULFATE P/F 1MG/ML 10ML VIAL5BX2MORPHINE SULFATE 50MG/ML VIAL20ML1