Free Sample General Prescription Template
Sample General Prescription
Date: October 8, 2085
Patient Information
Name: Katherine Connel
Date of Birth: January 1, 2050
Patient ID: 987654321
Prescription Details
Medication: Atorvastatin
Dosage Form (Tablet/Capsule/Liquid): Tablet
Strength: 40 mg
Quantity: 30 Tablets
Route of Administration: Oral
Frequency: Once daily
Duration of Therapy: 30 days
Refill Information
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No Refills
-
Number of Refills: 2
Substitution Allowed?
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Yes
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No
Prescribing Physician Information
Prescribing Physician: [YOUR NAME], M.D.
License Number: MD12345678
Contact Information: 222 555 7777
Special Instructions
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Take with a full glass of water.
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Do not consume grapefruit or grapefruit juice while on this medication.
Physician Signature
Date: October 8, 2085
Pharmacy Use Only
Pharmacy Name: HealthFirst Pharmacy
Pharmacy Address: Dayton, OH 45402
Pharmacist: Zena Frami
Date Dispensed: October 9, 2085
Comments: Checked for potential drug interactions.
