Free Professional Pharmaceutical Prescription Template
Professional Pharmaceutical Prescription
I. Prescriber's Information
|
Full Name: |
[YOUR NAME] |
|
License Number: |
12345678 |
|
Contact Number: |
222 555 7777 |
|
Email Address: |
[YOUR EMAIL] |
|
Address: |
Dallas, TX 85224 |
II. Patient Information
|
Full Name: |
Marcelo Green |
|
Date of Birth: |
01/01/2050 |
|
Contact Number: |
222 555 7777 |
|
Email Address: |
marcelo@you.mail |
|
Address: |
Dallas, TX 85224 |
III. Medication Details
|
Medication Name: |
Amoxicillin |
|
Dosage: |
500 mg |
|
Frequency: |
Take one capsule every 8 hours. |
|
Route of Administration: |
Take one capsule by mouth every 8 hours for 10 days. |
|
Duration: |
10 days |
|
Quantity: |
30 capsules |
IV. Diagnosis
Please provide a brief description of the diagnosis related to this prescription:
-
Bacterial Infection
V. Additional Instructions
If there are any specific instructions for this prescription, list them below:
-
Take medication with food
-
Avoid alcohol during treatment
-
Store medication in a cool, dry place
-
Other: _____________
VI. Prescriber's Signature
Signature:
Date: 08/11/2082
Please ensure that all sections are completed before submission. Retain a copy for your records.
