Medication Order Layout

I. Patient Information

Patient Name:	____________________________
Date of Birth:	____________________________
Patient ID:	____________________________
Contact Information:	____________________________

II. Prescribing Physician Information

Physician Name:	[YOUR NAME]
License Number:	____________________________
Practice Address:	____________________________
Contact Number:	____________________________

III. Medication Details

Medication Name:	____________________________
Dosage:	____________________________
Frequency:	____________________________
Duration:	____________________________

IV. Task Checklist

• Verify patient's current medication list

• Confirm medication allergies or sensitivities

• Review patient's medical history

• Explain potential side effects to the patient

• Ensure medication availability at the preferred pharmacy

V. Additional Instructions

Ensure all fields are completed accurately and legibly. Submit the completed form to the pharmacy along with any supplementary documents if necessary. Retain a copy for patient records.

VI. Signatures

Prescriber Signature:	____________________________
Patient Signature:	____________________________
Date:	____________________________

Prescription Templates @ Template.net