Drug pedigree: Fill out & sign online

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Click ‘Get Form’ to open the Prescription Drug Pedigree in our editor.
Begin by entering the wholesaler’s name at the top of the form. This identifies who is completing the pedigree.
Fill in the drug details, including the Legend Drug Name, Strength, Dosage Form, and Container Size. If applicable, check the box indicating that this is a repackaged drug.
Provide optional NDC information and complete the Reference Number, Lot Number, Quantity, Unique Serial #, Document Type, and Reference Date related to the sale.
In the Ownership History section, input details about the manufacturer and any wholesalers involved in previous transactions. Ensure to include names, addresses, dates purchased, and signatures where required.
Complete all necessary fields for each transaction listed under Physical Distribution History. Repeat as needed for additional sales.
Finally, sign and date at the bottom of the form to affirm that all information is accurate and complete.

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