Harper's Pharmacy Inc.
CONTROL MEDICATION LOG SHEET
(877) 778-3773
FAX (800) 951-7948
770 Magnolia Ave #1G
DISPOSITION OF UNUSED PORTION OF DRUG
Corona, CA 92879
DATE DISCONTINUED_______________________AMOUNT REMAINING_______________
DATE DISPOSED_____________________HOW DISPOSED__________________________
AUTH SIGNATURE___________________________________________________________
WITNESS: NURSE__________CONSULTANT RPH__________ADMINISTRATOR__________
***Two of the following individuals must initial as witnesses upon signing this form for controlled
medication destruction: Nurse, Consultant RPH or Administrator***
AMT
Date
Time
Initial
AMT
Date
Time
Initial
AMT
Date
Time
Initial
AMT
Date
Time
Initial
Initial
Name
Initial
Name
Initial
Name
Initial
Name