Free Hospital Prescription Template
Hospital Prescription
[YOUR COMPANY NAME]
Patient Information
Name: Talia Jacobs
Date of Birth: January 15, 2050
Patient ID: 123456789
Prescribing Physician Information
Physician Name: [YOUR NAME]
License Number: ABC123456
Specialization: Internal Medicine
Contact Information: [YOUR EMAIL]
Prescription Details
Date of Prescription: March 1, 2080
Medication Name: Amoxicillin
Dosage Form: Capsule
Strength: 500 mg
Quantity: 30 capsules
Instructions for Use:
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Take one capsule by mouth every 8 hours for 10 days.
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Take with food to avoid stomach upset.
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Finish the entire course of medication even if symptoms improve.
Refills Authorized: 0
Substitution Allowed:
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Yes
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No
Warnings and Precautions
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Do not take this medication if you are allergic to penicillin or similar antibiotics.
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Seek immediate medical attention if you experience any severe allergic reactions such as difficulty breathing, hives, or swelling of the face, lips, tongue, or throat.
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Inform your physician of any existing medical conditions, particularly kidney disease, asthma, or a history of allergies.
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Avoid alcohol consumption during the course of this treatment.
Additional Notes
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If symptoms persist after completing the medication, please schedule a follow-up appointment.
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Contact [YOUR COMPANY NAME] immediately if you experience any side effects or have concerns regarding the medication.
Physician Signature:
[YOUR NAME]
Date: March 1, 2080
Pharmacy Use Only
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Date Dispensed: ___________________
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Dispensed by: _____________________
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Notes: _____________________________
