Doctor’s Prescription Note
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
