Free Private Prescription Template
Private Prescription
[YOUR NAME], MD
[YOUR COMPANY NAME]
Contact: [YOUR EMAIL]
Date: October 10, 2083
Patient Name: Bennie Goodwin
Date of Birth: April 15, 2050
Address: Lubbock, TX 79401
Prescription:
Medication: Amoxicillin
Dosage: 500mg
Instructions: Take one capsule orally three times a day for 7 days
Refill: No Refills
This is a private prescription and is to be used only by the patient identified above.
Signature:
[YOUR NAME], MD
