Free Medical Prescription Outline Template
Medical Prescription Outline
I. Patient Information
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Patient Name: ____________________________ |
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Date of Birth: _____________________________ |
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Contact Information: _____________________ |
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Address: _________________________________ |
II. Prescribing Physician's Details
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Physician Name: [YOUR NAME] |
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Contact Number: ________________________ |
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License Number: ________________________ |
III. Medication Details
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Medication Name: ______________________ |
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Dosage: _________________________________ |
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Route of Administration: ________________ |
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Frequency: ______________________________ |
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Total Quantity: __________________________ |
IV. Instructions and Precautions
Please review the following instructions and precautions:
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Take medication with food to avoid stomach upset.
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Do not operate heavy machinery while on this medication.
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Store medication at room temperature.
V. Additional Notes
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
VI. Signatures
Please complete and sign the form below:
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Physician Signature: ____________________ |
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Patient Signature: _______________________ |
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Date: ____________________________________ |
If you have any questions about the prescription, please contact your physician or pharmacist for further instructions.
