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 Certificate of Transfer & Destruction of Controlled Substance
(41 Form)

Please fill out the following form for your pharmaceutical returns OR if you wish to use the handwritten form then print the form here.

In order to process your returns, please make sure you fill in all the required fields. The required fields have been marked in red.
Pharmacy Name:
Pharmacy Address:   Ref #:
Pharmacy Address Cont.:
City, State,Zip:
DEA Number:
DEA Expiration Date:
Your Name:
Your Phone:
Your Email:
you will receive a copy of this 41 form at email address entered for your records.
Additional Email:
Enter any additional email addresses to which you want a copy of this 41 form sent. Separate addresses using commas records.

Need Help? Instructions
 
 DEA CLASS
 NAME OF DRUG / PREPARATION
 NUMBER
OF
CONTAINERS
 UNITS
PER
CONTAINER
 		CONTROLLED SUBSTANCE CONTENT
 NDC#
 MANUFACTURER NAME
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
  Date: Completed By:
 

Pharmaceutical Credit Corporation

Mailing Address:

P.O. Box 1684
Brentwood, TN 37027-1684

Shipping Address:

130 Seaboard Lane, Suite A-6
Franklin, TN 37067

Telephone: (615) 373-4262
Fax: (615) 373-7727

 



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