Free Prescription List Template
Prescription List
Date: 01/01/2083
Patient Information
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Patient Name: Brenda Boyle
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Date of Birth: 03/15/2050
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Address: Eugene, OR 97401
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Contact Number: 222 555 7777
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Email: brenda@you.mail
Physician Information
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Physician's Name: [YOUR NAME]
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Physician's Contact Information:
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Phone: 222 555 7777
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Email: [YOUR EMAIL]
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Medication List
|
Medication Name |
Dosage |
Frequency |
Duration |
Start Date |
End Date |
Notes |
|---|---|---|---|---|---|---|
|
Amoxicillin |
500 mg |
Twice a day |
7 days |
01/01/2055 |
07/01/2055 |
Take with food |
|
Lisinopril |
20 mg |
Once daily |
Indefinite |
01/01/2055 |
N/A |
Take in the morning |
|
Ibuprofen |
400 mg |
Every 6 hours (PRN) |
As needed |
01/01/2055 |
N/A |
Only for pain, max 4 doses |
|
Metformin |
500 mg |
Twice a day |
Ongoing |
01/01/2055 |
N/A |
Take with meals |
Additional Instructions
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Store medications at room temperature unless otherwise specified.
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Follow the exact dosage and timing prescribed.
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Contact [YOUR NAME] immediately if any side effects occur.
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Review medication with your physician during follow-up on 01/15/2055.
Signature
Physician's Signature:
Patient's Signature:
Emergency Contact
In case of emergency, contact [YOUR COMPANY NAME] at [YOUR COMPANY NUMBER].
