Free Prescribed Medication Template
Prescribed Medication
Prescription Date: 08/12/2080
Prescription Number: RX-2080-987654
I. Patient Information
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Patient Name: Nadette Ritchie
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Date of Birth: 04/15/2050
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Patient Address: Salem, OR 97301
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Phone Number: 222 555 7777
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Email Address: nadette@you.mail
II. Prescribing Physician Information
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Physician Name: Dr. [YOUR NAME]
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Physician License Number: 1234567890
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Practice Name: [YOUR COMPANY NAME]
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Address: [YOUR COMPANY ADDRESS]
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Phone Number: [YOUR COMPANY NUMBER]
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Email Address: [YOUR EMAIL]
III. Medication Details
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Medication Name: Lisinopril
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Dosage Strength: 10 mg
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Dosage Form: Tablet
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Quantity to Dispense: 30 tablets
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Refills: 2
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Directions for Use: Take 1 tablet orally once daily with water.
IV. Additional Instructions or Information
Monitor blood pressure regularly and report any significant changes.
V. Allergies/Warnings
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Known Allergies: Penicillin
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Any Other Contraindications: Avoid use with potassium supplements without consultation.
Substitution Permitted:
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Yes
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No
Generic Substitution:
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Yes
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No
VI. Follow-Up Appointment
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Date: 09/12/2080
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Time: 2:30 PM
Prescribing Physician’s Signature:
Date: 08/12/2080
This prescription is valid until 12/12/2080 unless otherwise stated.
Important Notice:
This prescription is for the indicated patient only. Sharing this medication with others or improper use is strictly prohibited.
