Rx-Only Purchaser Attestation

Some products sold by Keystone Supply Group LLC are labeled Rx only or carry the statement Caution: Federal law restricts this device to sale by or on the order of a licensed healthcare practitioner. Under 21 CFR 801.109, these products may be sold only to licensed healthcare facilities, licensed practitioners, or purchasers acting on a practitioner's order. Before we can ship an Rx-only product, the purchaser must complete the following.

Required information

• Facility or practice legal name and facility type.
• License type, license or certificate number, and issuing state.
• Name and credential of the licensed practitioner responsible for the order.
• Name, title, and date of the person completing this attestation.

Certification

I certify that I am purchasing on behalf of a licensed healthcare facility, a licensed healthcare practitioner, or an organization ordering under the direction of a licensed practitioner, and that the license information I have provided is accurate and current. I understand that products labeled Rx only are restricted by federal law (21 CFR 801.109) to sale by or on the order of a licensed practitioner, that they will be used only under such practitioner's direction, and that Keystone Supply Group LLC relies on this certification to fulfill my order and may verify it and keep it on file.

What happens next

KSG verifies license information with the issuing board before the first Rx-only shipment and keeps this attestation on file. Orders that cannot be verified are canceled and refunded. Contact Orders@KeystoneSupplyGroup.com or (507) 237-6036 with questions.