All YELLOW areas must be completed by the customer.

Please read back of form for information about completing this form properly.

Blue Ridge Medical must return any form that is Incomplete or Incorrect.

ONLY Schedule 2 narcotics can be ordered on this form.

Blue Ridge Medical must have the physical form before the order can be filled.

Narcotics must be shipped to the address Pre-printed on the form.

Customer may keep back copy of 222 Form.

If back copy is not removed it will be returned with your order.

Blue Ridge Medical has the right to return any order form without filling the order.