Free Doctor’s Prescription Note Template

Doctor’s Prescription Note

Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]

I. Patient Information

Field

Details

Patient Name

Ernesto Murphy

Date of Birth

February 15, 2050

Address

Oklahoma City, OK 73101

Contact Number

222 555 7777

Date of Prescription

January 1, 2090

II. Medication Details

Medication Name

Dosage

Frequency

Quantity

Refills

Amoxicillin

500 mg

Every 8 hours

30 capsules

2

Lisinopril

10 mg

Once daily

30 tablets

1

Metformin

500 mg

Twice daily

60 tablets

3

Ibuprofen

400 mg

Every 6 hours

20 tablets

0

Sertraline

50 mg

Once daily

30 tablets

2

Albuterol Inhaler

90 mcg

As needed

1 inhaler

0

Vitamin D3

1000 IU

Once daily

30 capsules

1

Levothyroxine

75 mcg

Once daily

30 tablets

1

Aspirin

81 mg

Once daily

30 tablets

1

III. Additional Information

Doctor’s Name: [YOUR NAME]
License Number: MD1234567
Contact Number: 222 555 7777
Date: January 1, 2050

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