Dea Form 106 - Rx-Wiki Page 2
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2LIST OF CONTROLLED SUBSTANCES LOST
DEA-106 (Dec. 1985) Pg. 2
Trade Name of Substance or Preparation
Name of Controlled Substance in Preparation
Dosage Strength and Form
Quantity
5 mg Tablets
Examples:
Desoxyn
Methamphetamine Hydrochloride
3 x 100
50 mg/ml Vial
Demerol
Meperidine Hydrochloride
5 x 30 ml
Robitussin A-C
Codeine Phosphate
2 mg/cc Liquid
12 Pints
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I certify that the foregoing information is correct to the best of my knowledge and belief.
Signature
Title
Date
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