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Dr. Sham Quack, M.D.
666 Dead End Ln.
Zombie City, TX 00000

Date: 3/14/17
Name: Special Little Snowflake
Address: 2700 Avalanche of Indifference Rd
DOB: 3/13/17

Take 1 bullet PO TID PRN pain
#90 (ninety)
refills: PRN

Substitution Permissible: Sham Quack

Brand Medically Necessary: